Sample Coded report for Rotator Cuff repair CPT code

PREOPERATIVE DIAGNOSIS:

1. Right shoulder rotator cuff tear.
2. Right shoulder SLAP tear.
3. Right shoulder impingement.
4. Right shoulder AC DJD.

POSTOPERATIVE DIAGNOSIS:

1. Right shoulder rotator cuff tear.
2. Right shoulder SLAP tear.
3. Right shoulder impingement.
4. Right shoulder AC DJD.
5. Right shoulder biceps tear

INDICATION FOR PROCEDURE:

Brief History:  A 76 y.o. -year-old male  has had persistent shoulder pain and functional limitation despite conservative management.  MRI showed above-mentioned findings.  Operative and non-operative options were discussed and time was allowed for questions. Risks of surgery were discussed. Signed consent was obtained, and patient was scheduled for above-mentioned procedure.

PROCEDURE PERFORMED:

1. Right shoulder arthroscopic rotator cuff repair.
2. Right shoulder arthroscopic biceps tenodesis.
3. Right shoulder arthroscopic subacromial decompression.
4. Right shoulder arthroscopic distal clavicle excision.
5. Right shoulder arthroscopic slap debridement
6. Insertion of amnion patch 2 x 3 cm to the right shoulder

ANESTHESIA:

General with interscalene block

COMPLICATIONS: None

ESTIMATED BLOOD LOSS: minimal

PROCEDURE IN DETAIL:

Preoperatively, the patient received prophylactic antibiotics.  Pt underwent interscalene block in the preoperative holding area.  Pt was then taken to the OR, placed supine on the OR table.  After adequate anesthesia was induced, the Right shoulder was identified as correct surgical site.  Pt was placed in a well-padded lateral decubitus position, rotated back 30 degrees and maintained in this position with a bean bag.  Shoulder was examined under anesthesia and found to forward flex to 180 and abduct to 180 degrees.  Pt could externally rotate to 90 and internal rotate to 85.  There was no palpable instability with anterior posterior load shift test.  The operative arm was prepped and draped in usual sterile fashion and another 45 degrees of abduction and 30 degrees of flexion with 10 pounds of traction.  Standard posterior portal was made.  Camera was inserted.  The shoulder was inspected.  The humeral head sat well within the glenoid.  Articular surfaces were intact.

There was a superior labral tear extending into the biceps tendon.  There was obvious biceps tendon instability due to the adjacent large retracted rotator cuff tear involving the supraspinatus.  Subscapularis was intact.  The infraspinatus was torn as well both the supraspinatus and infraspinatus were retracted.  Under direct visualization using a spinal needle an anterior portal was established and a plastic cannula was inserted.  Arthroscopic shaver was introduced and limited debridement of superior labral tear was carried out.  Attention was turned to the subacromial space.  The camera was inserted through the posterior portal and the inflow cannula was inserted through the anterior portal.  Under direct visualization using a spinal needle a lateral portal was established 3 cm distal to the anterolateral corner of the acromion.  Small metal trocar and cannula were inserted followed by insertion of arthroscopic shaver.  Arthroscopic shaver was introduced and used to perform bursectomy.

Superiorly there was obvious signs of impingement it was felt the patient would benefit from subacromial decompression.  With the camera in the lateral portal the helical burr was introduced posteriorly.  Using cutting block technique, acromioplasty was carried out.  Care was taken to leave no overhanging bone anteriorly or laterally.  Attention was then turned to the AC joint.  There was obvious degenerative changes with inferior spurring causing impingement it was felt the patient would benefit from distal clavicle excision.  With the camera in the lateral portal the anterior trocar and cannula were removed and redirected to the soft spot from the AC joint.  The helical burr was reintroduced and after debriding the acromial facet, 1 cm distal clavicle was excised.  Care was taken to leave the superior and posterior capsule in place.  Attention was turned back to the rotator cuff.  This was a large retracted rotator cuff tear.

It it involved the supraspinatus and infraspinatus and was retracted to a point just lateral to the glenoid surface.  Arthroscopic shaver was introduced and used to release adhesions above and below the rotator cuff tendons grasper was introduced and mobilization of the rotator cuff was achieved.  It was felt the patient would benefit from double row rotator cuff repair.  The exposed greater tuberosity was gently excoriated.  For draw tight 3.2 anchors were placed along the medial edge of the exposed greater tuberosity footprint.  Both arms of the single suture from the posterior and anterior anchors as well as both arms of each of the double loaded sutures from the 2 middle anchors were passed through the torn rotator cuff and tied arthroscopically with modified Roeder knots the retracted tendon also had a bilaminar component in both layers were grabbed and tied with the sutures.

The 12 suture arms were then divided among the 3 4.75 X Twist anchors which were placed along the lateral edge of the exposed greater tuberosity footprint.  This completed the arthroscopic double row suture bridge rotator cuff repair.  Prior to fixation of the rotator cuff the biceps tendon had been released from its superior labral insertion site and tagged with a 2.  Suture loop.  This had been placed in the anterior x twist anchor which completed the arthroscopic biceps tendon tenodesis.   Prior to cinching down the lateral row of the rotator cuff a 2 x 3 cm amnion patch had been placed at the site of the rotator cuff repair to help with neovascularization early healing and decreased inflammatio.

Final arthroscopic pictures were obtained.  Arthroscopic equipment was removed.  Portal sites were closed with benzoin, Steri-Strips, dry bulky dressing, and abduction sling device were applied.  The patient was transferred to the stretcher, awoken by anesthesia without complication, and transferred to recovery in good condition.

29827 SURGICAL ARTHROSCOPY SHOULDER W/ROTATOR CUFF RPR; (-RT Right side of body)

29828 SURGICAL ARTHROSCOPY SHOULDER BICEPS TENODESIS; (-RT Right side of body)

29824 – SURGICAL ARTHROSCOPY SHOULDER DSTL CLAVICULC; (-RT Right side of body); (-XU Unusual Non-Overlap Svc)

29826 SURGICAL ARTHROSCOPY SHO W/CORACOACRM LIGM RLS; (-RT Right side of body); (-XU Unusual Non-Overlap Svc)

M75.121 – Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic

S43.431A – Superior glenoid labrum lesion of right shoulder, initial encounter