This is an authentic coding case for an inpatient clinic for…

Question Answered step-by-step This is an authentic coding case for an inpatient clinic for… This is an authentic coding case for an inpatient clinic for Musculoskeletal system.DIRECTIONS: Please review the documentation of the patient encounter and code the case.QUESTION: What are the ICD-10-CM and ICD-10-PCS codes for this case? (There are 8 codes total) Department of Orthopedics Subjective:  In the past 24 hours has experienced minimal pain. No complaints this morning.  Patient Active Hospital Problem List: No active hospital problems. Assessment and Plan: POD 1 s/p L RTSA -Complete postop antibiotics -continue routine postop care -No motion to shoulder. -Anticipate discharge home today  Diagnosis: Left Shoulder Glenohumeral Osteoarthritis with rotator cuff insufficiency, AC joint arthropathy Surgery: 1. Left Reverse Total Shoulder Arthroplasty 2. Left biceps tenodesis 3. Left subscapularis tenotomy 4. Left Mumford procedureSubjective: No acute events overnight. Patient had severe nausea, emesis yesterday that has since resolved. Doing much better this morning. Endorses adequate pain control. Anticipates DC home today.  Assessment and Plan: The patient is a 64 y.o. female s/p left reverse TSA. Doing well. – NWB with left upper extremity; no ER. Maintain in sling. – Pain control: APS catheters, Oxycodone PRN – PT/OT/00B as tolerated – DVT prophylaxis: SCD’s, early ambulation – Dispo: DC home today. F/u Dr. in 2-3 weeks. DC instructions reviewed with patient Department of Orthopedics Division of Hand Surgery Pre-Operative NotePlanned procedure: Left total versus reverse shoulder arthroplasty, Mumford procedureHistory: a 64 y.o. right hand dominant female who is being seen in the Orthopaedic clinic in preparation for Left total versus reverse shoulder arthroplasty, Mumford procedure. The patient has been followed up in the Hand clinic for left shoulder degenerative disease of the glenohumeral joint and AC joint arthrosis. After an extensive discussion of natural history of condition, surgical options, recommended surgical options, nature, rationale for, risks and benefits of recommended procedure she was keen to proceed with the procedure recommended. Past Medical History Diagnosis • GERD (gastroesophageal reflux disease) • Arthritis • Thyroid diseasePast Surgical History Procedure • Hand surgery right thumb • Tubal ligationAssessment & Plan: Impression: Left glenohumeral arthritis, AC joint arthrosisPlan:  -OR on with Dr for Left total versus reverse shoulder arthroplasty, Mumford procedure. – This procedure has been fully reviewed with the patient and written informed consent has been obtained . – Appreciate clearance from PCP in . Pre-operative labs previously performed, however not available for our review.  Department of Orthopaedics Discharge Summary Principal Diagnosis (es): Left Shoulder Glenohumeral Osteoarthritis with rotator cuff insufficiency, AC joint arthropathySecondary Diagnosis and Complications: Past Medical HistoryDiagnosis • GERD (gastroesophageal reflux disease) • Arthritis • Thyroid disease • Blood transfusion without reported diagnosis No reactions.  All of the above were present on admission Operations and Major Procedures: 1. Left Reverse Total Shoulder Arthroplasty 2. Left biceps tenodesis 3 . Left subscapularis tenotomy 4. Left Mumford procedure  Hospital course: For full details please refer to patient’s H&P and progress notes. In brief , is a 64 y.o. year old female who has been followed in the Orthopaedic Hand/Upper Extremity clinic for chronic, debilitating shoulder pain recalcitrant to non-operative treatment measures. She was admitted for elective arthroplasty. On the patient was taken to the OR for the above procedure. Patient tolerated this procedure well and was transferred to floor postoperatively. Patient was NOT allowed to weight bear on the operative upper extremity, was not allowed any active shoulder range of motion, and was not allowed external rotation beyond O degrees. dressings were evaluated on post operative day# 1 and were clean, dry and intact. was seen by Physical Therapy who taught patient the above postoperative restrictions and recommended discharge home. On POD 1, patient had nausea and emesis that did not resolve to the evening; this necessitated another overnight stay. On the day of discharge patient remained hemodynamically stable, tolerating a diet and afebrile. Their pain was well controlled with oral medications. Patient was discharged on POD#2 to home in good condition. Patient is to follow up in Dr. clinic in 2 weeks for x-rays of the operative shoulder and a wound check.  Department of Orthopedics Operative Note PREOPERATIVE DIAGNOSIS: Left Shoulder Glenohumeral Osteoarthritis with rotator cuff insufficiency, AC joint arthropathy POSTOPERATIVE DIAGNOSIS: Left Shoulder Glenohumeral Osteoarthritis with rotator cuff insufficiency, AC joint arthropathy OPERATION PERFORMED: 1. Left Reverse Total Shoulder Arthroplasty 2. Left biceps tenodesis 3. Left subscapularis tenotomy 4. Left Mumford procedureSPECIMEN: left humeral head COMPLICATIONS: no complications were notedIMPLANTS: Exactech Equinoxe Reverse Total Shoulder Arthroplasty System  FINDINGS: Rotator Cuff: Supraspinatus: intact. lnfraspinatus: poor quality. Teres minor: intact. Subscapularis: intact. Glenoid Wear: B2 Humeral Head: Peripheral osteophtes Biceps Tendon: intact with tenosynovitis INDICATION FOR PROCEDURE: The patient is a pleasant 64 y. o. female who has a long history of left shoulder pain. Radiographs revealed significant glenohumeral arthritis. The non-operative and operative options were explained to the patient in the outpatient setting. Patient decided to undergo a shoulder arthroplasty (total versus reverse) and all other indicated procedures . Informed consent was obtained .  OPERATIVE NOTE: After informed consent, correct site and procedure were identified, the patient was brought to the Operating Room, placed under general anesthesia. She was prepped and draped in sterile fashion in the beach chair position with the upper extremity held by a Spider arm positioner. Preoperative time-out was performed. Preoperative antibiotics were administered. An approximately 15 cm incision was made overlying the deltopectoral interval. Sharp and electrocautery dissection were used to extend this down to the deltoid fascia, which was then sharply incised. The cephalic vein was identified, retracted medially, and vessels were cauterized as they were encountered. The fascia over the anterior aspect of the shoulder joint was identified. All adhesions under the deltoid were released with a combination of sharp and blunt dissection. A Brown deltoid retractor was inserted. The lateral border of the conjoined tendon was identified, and an Army-Navy was used to retract the conjoined tendon medially. The arm was externally rotated, and the anterior vasculature to the proximal humerus was cauterized medially and laterally. The biceps tendon was identified and the fascia overlying the bicipital groove was incised longitudinally, following the biceps tendon up through the rotator interval to perform the glenohumeral joint arthrotomy. The biceps tendon was transected at the level of its insertion on the superior glenoid labrum.  The rotator cuff was examined and felt to be inadequate for conventional shoulder arthroplasty. The subscapularis insertion was elevated along with the underlying capsule with electrocautery. A Hohmann retractor was inserted while external rotation and extension were applied to the arm. Electrocautery was used to peel the remainder of the subscapularis and all of the capsule from the anterior, inferior and posterior aspect of the proximal humerus. The proximal humerus osteotomy was performed using an oscillating saw and the humeral cutting guide, with the proximal portion of the cut approximating at the greater tuberosity. The humeral cut was made with approximately 25 degrees of retroversion. A proximal humerus protector was placed, and attention was turned to the glenoid.  The proximal humerus was retracted in a posteroinferior direction to the glenoid, while bringing the arm into neutral flexion and external rotation. The entire glenohumeral capsule was circumferentially released along with excision of the glenoid labrum. A curved osteotome was placed under the capsule anteriorly and used to free all adhesions deep to the subscapularis on the anterior aspect of the glenoid. A Jobe retractor was placed anteriorly, a Hohmann in the posterosuperior position and a Wolff retractor in the posteroinferior position affording excellent visualization of the glenoid. Cartilage was scraped off inferiorly with a Cobb. The glenoid was divided into quadrants to determine the appropriate position of the central cage site, and the central cage hole was drilled using the posterior augment guide. The glenoid was irrigated with pulsed lavage. The glenoid baseplate was obtained, and the central cage was packed with cancellous autograft from the humeral head. The baseplate was placed into the central cage hole in the glenoid and firmly seated against the glenoid face. Appropriate inferior overhang was confirmed 4 screws were placed through the baseplate into the glenoid bone; 4 each with excellent bony fixation inferior, superior, anterosuperior and posteroinferior. The locking heads for each screw were placed into the baseplate. The glenosphere was obtained and placed gently onto the base plate Morse taper. The glenosphere set screw was placed and turned down easily to a level just below the glenosphere surface. The glenosphere was then impacted onto the Morse taper of the baseplate and the set screw turned down firmly. No soft tissue or bony impingement sites were evident.  Retractors were removed, the proximal humerus was re-exposed, proximal humerus protector removed. The proximal humerus was sequentially reamed and broached until appropriate resistance was met. After irrigation with pulsed lavage, a trial prosthesis was placed into the proximal humerus. Glenohumeral joint was reduced with the patient completely paralyzed. This required recutting the humerus and recessing the supraspinatus inseration, and we did not intraoperative nondisplaced fracture of the lesser tuberosity. Soft tissue tension was assessed and joint stability tested . The construct demonstrated no impingement with the arm in adduction/internal rotation as well extension/external rotation of 60 / 60. Shuck was 2 mm. The joint was dislocated and the proximal humerus re-exposed . Trial components were removed and the proximal humerus was irrigated with pulsed lavage. Final prosthesis was obtained and assembled on the back table. Prosthesis was placed into ihe proximal humerus in a press-fit manner with excellent fit. The glenohumeral joint was reduced and soft tissue balance and stability were assessed and determined to be excellent. The subscapu!aris tendon was then examined for compliance and length . The subscapularis tendon was left as a tenotomy due to poor compliance and quality of the tendon. A biceps tenodesis to the pectoralis major insertion was accomplished with Fiberwire suture, and the remainder of the proximal biceps tendon was excised. We dissected superiorly through the soft tissues on to the clavicle. Dissection was carried distally until the AC joint was encountered. Retractors were placed anteriorly and posteriorly and a sagittal saw was used to resect approximately 1 cm of the distal clavicle . The posterior prominence of the distal clavicle was further shortened. The entire wound was then irrigated copiously with normal saline solution using pulsed lavage . In addition, prior to implantation of each component of the prosthesis, lrracept solution was applied to the entire wound followed by irrigation with normal saline solution. Platelet-rich plasma and Vancomycin powder were sprayed into the glenohumeral joint and throughout the wound. The deltoid fascia was closed with interrupted sutures. Platelet poor plasma and Vancomycin powder were placed in the subcutaneous layer, and this layer was closed with interrupted sutures . An absorbable subcuticular stitch was placed in the skin . A double layer of Dermabond was applied , followed by a sterile adhesive dressing. The patient’s arm was placed in a sling . The patient was awakened from anesthesia, and transferred to the Recovery Room in good condition.  Post-Operative Plan: 1. Admit as inpatient. 2. Pain control. 3. IV Antibiotics 4. Physical therapy for reverse total shoulder arthroplasty therapy protocol.  Health Science Science Nursing HCMT 2025 Share QuestionEmailCopy link Comments (0)

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