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View MR 002395

MR 002395

Operative Report

Pre-operative Diagnosis: Acute rotator cuff tear

Post-operative Diagnosis: Acute rotator cuff tear, synovitis

Procedures:

1) Rotator cuff repair

2) Biceps Tenodesis

3) Claviculectomy

4) Coracoacromial ligament release

Indication: Rotator cuff injury of a 32-year-old male, sustained while playing soccer.

Findings: Complete tear of the right rotator cuff, synovitis, impingement.

Procedure: The patient was prepared for surgery and placed in left lateral decubitus position. Standard posterior arthroscopy portals were made followed by an anterior-superior portal. Diagnostic arthroscopy was performed. Significant synovitis was carefully debrided. There was a full-thickness upper 3rd subscapularis tear, which was repaired. The lesser tuberosity was debrided back to bleeding healthy bone and a Mitek 4.5 mm helix anchor was placed in the lesser tuberosity. Sutures were passed through the subcapulans in a combination of horizontal mattress and simple interrupted fashion and then tied. There was a partial-thickness tearing of the long head of the biceps. The biceps were released and then anchored in the intertubercular groove with a screw. There was a large anterior acromial spur with subacromial impingement. A CA ligament was released and acromioplasty was performed. Attention was then directed to the

supraspinatus tendon tear. The tear was V-shaped and measured approximately 2.5 cm from anterior to posterior. Two Smith & Nephew PEEK anchors were used for the medial row utilizing Healicoil anchors. Side-to-side stitches were placed. One set of suture tape from each of the medial anchors was then placed through a laterally placed Mitek helix PEEK knotless anchor which was fully inserted after tensioning the tapes. A solid repair was obtained. Next there were severe degenerative changes at the AC joint of approximately 8 to 10 mm. The distal clavicle was resected taking care to preserve the superior AC joint capsule. The shoulder was thoroughly lavaged. The instruments were removed and the incisions were closed in routine fashion. Sterile dressing was applied. The patient was transferred to recovery in stable condition.

What CPT® coding is reported for this case?

View MR 007400

MR 007400

Radiology Report

Patient: J. Lowe Date of Service: 06/10/XX

Age: 45

MR#: 4589799

Account #: 3216770

Location: ABC Imaging Center

Study: Mammogram bilateral screening, all views, producing direct digital image

Reason: Screen

Bilateral digital mammography with computer-aided detection (CAD)

No previous mammograms are available for comparison.

Clinical history: The patient has a positive family history (mother and sister) of breast cancer.

Mammogram was read with the assistance of GE iCAD (computerized diagnostic) system.

Findings: No dominant speculated mass or suspicious area of clustered pleomorphic microcalcifications is apparent Skin and nipples are seen to be normal. The axilla are unremarkable.

What CPT® coding is reported for this case?

A 47-year-old female presents to the operating room for a partial corpectomy on one upper thoracic vertebral body, T3. Two surgeons are performing the surgery. One surgeon performs the transthoracic approach and excises the damaged portion of the vertebral body. The second surgeon inserts a bone graft into the vertebral gap, closing the gap, and inserts a metal plate. Both surgeons work together, each as a primary surgeon.

How does each surgeon report their portion of the surgery?

(A 60-year-old man presents for examination of the entire rectum andsigmoid colon. Two polyps are found in the sigmoid colon and removed usingablation. What CPT® and ICD-10-CM codes are reported?)