Case -AUDIT REPORT T8.2 OPERATIVE REPORT, SHOULDER

Essay

Case
-AUDIT REPORT T8.2 OPERATIVE REPORT, SHOULDER
LOCATION: Outpatient, Hospital
PATIENT: Stan Hope
SURGEON: Mohomad Almaz, MD
PREOPERATIVE DIAGNOSIS: Left shoulder pain and numbness, past
shoulder injury
POSTOPERATIVE DIAGNOSIS: Normal shoulder
PROCEDURE PERFORMED: Diagnostic arthroscopy, left shoulder
CLINICAL HISTORY: This is a 57-year-old with a 10-year-old rotator cuff tear injury to his left shoulder. The patient does heavy lifting for a living. For the past 6 months the patient has been experiencing pain in this shoulder with some numbness and tingling traveling down the arm. X-rays were normal. Decision was made to go in with an arthroscope to try and uncover a reason for this pain and numbness.
OPERATIVE REPORT: Under general anesthesia, the patient was laid in the beach chair position on the operating room table. The left shoulder was examined and found to be stable. There is full range of motion of this shoulder also. The extremity was then prepped and draped in the usual fashion. A standard posterior arthroscopic portal was created, and the camera was introduced. First the back of the joint was inspected, and this did not show any evidence of damage. The anterior ligament structures were normal.
The biceps attachment and its transit through the joint were normal. Subscapularis was intact with no abnormality. Old scarring of the rotator cuff was noted. But all looked as it should. Nothing abnormal was seen. The camera was then removed out of the glenohumeral joint and placed in the subacromial space. There was excellent visualization of this area. No abnormalities could be identified, and there was no evidence of any impingements. The camera was then removed from the subacromial space. The area was then infiltrated with Marcaine. The posterior portal was then closed with absorbable sutures and Steri-Strips, and a Mepore dressing was placed on it. The arm was then placed in a sling; the patient awakened and was placed on his hospital bed and taken to the recovery room in good condition.
T8.2:
SERVICE CODE(S): 29805_____________________________________________
ICD-10-CM DX CODE(S): S43.422_______________________________________
INCORRECT/MISSING CODE(S): ________________________________________