jeudi 30 avril 2015

29806 and 29999 vs 29806 only

Hi fellow coders.

The doctor stated that he performed a posterior labral repair and capsulorraphy. He wanted it coded 29806 and 29999. I am not sure if there are two codes here.

Can someone please enlighten after reading the operative report as to what I am missing? Thank you so much. Any coding suggestions would be greatly appreciated.

POSTOPERATIVE DIAGNOSES:
1. Left shoulder pain.
2. Left shoulder posterior instability.
3. Left shoulder posterior labral tear.

PROCEDURES PERFORMED:
1. Left shoulder arthroscopy.
2. Left shoulder posterior labral repair with capsulorrhaphy.

Arm was placed in 10 pounds of longitudinal traction and a mark was made 2 fingerbreadths down, 2 fingerbreadths medial from the posterolateral aspect of the acromion. An
18-gauge spinal needle was inserted into the glenohumeral joint. Joint was distended with 60 mL of sterile saline. An #11 blade scalpel was used to incise the skin. Arthroscope was introduced in the posterior aspect of glenohumeral joint and a diagnostic arthroscopy was begun. There was no evidence of chondromalacia over the glenoid or humeral surfaces. There was no evidence of superior labral tear. No evidence of anterior labral tear. Subscapularis tendon was in good condition. Biceps tendon was in good condition. No evidence of rotator cuff tear involving the supraspinatus, infraspinatus or teres minor tendons. There was no evidence of loose bodies in the axillary pouch. No evidence of anterior or posterior haggle lesion. There was a small rent in the posterior capsular structures. An
anterior portal was established using outside-in technique. An 18-gauge spinal needle was inserted above the superior border of the subscapularis muscle. An 11-blade scalpel was used to incise the skin. A 7-0 cannula from Arthrex was introduced in the glenohumeral joint. Superior and anterior labrum were probed and felt to be stable. The posterior labrum was felt to be debrided and it was felt to be unstable and torn. A second anterior portal was established as well as a working portal posteriorly was
established. Reviewing was then performed from the anterior portal. The posterior labrum was probed and felt to be unstable. A periosteal elevator was used to mobilize the labrum. The posterior aspect of the glenoid was decorticated using a shaver as well as a red rasp. Then, through a stab incision 2 Griffin anchors were placed into the posterior aspect of the labrum. These were then passed through the labral and capsular tissue using an ideal suture passer then the knots were tied using SMC knots with
alternating half hitches x 5 with switching of the lateral post for the last 2 half hitches. Once all intraarticular work was complete, arthroscopic instrumentation was removed from the shoulder. Half of 3-0 Prolene was used to approximate skin edges. Sterile dressing was applied. Sling was applied. The patient was awoke from general endotracheal intubation and brought to the PACU in stable condition.



29806 and 29999 vs 29806 only

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