Report states :
Through a posterolateral portal the Glenohumeral joint was fairly normal. There was very minimal chondromalacia noted. The supra- and infraspinatus was seen to be torn and retracted back to the mid-humeral level. Biceps tendon minimally frayed. The rest of the exam was unremarkable without labral tears or SLAP lesion. The scope was then withdrawn and through a transverse incision in the deltoid skin . . . . ( he goes on to
describe the rotator repair ). Then states: The subacromial decompression was completed and the deltoid was allowed to approximate spontaneously and the skin closed with 5-0 nylon, etc.
Doctor wants 23412 and 29823
I am thinking just the 23412. I don't see where he did any debridement during the
arthroscopy. He mentions the fraying and chondromalacia, but doesn't state that he did
anything with it ?
Also, what code would I use for the open subacromial decompression, or is it inclusive?
Generally , my doctors have done the subacromial decompression during the scope.
Please help ?
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