cpt code with modifier for Postoperative Diagnosis: SLAP lesion…
cpt code with modifier for Postoperative Diagnosis: SLAP lesion right shoulder. Partial rotator cuff tear. INDICATIONS: Patient is a 26-year-old male who has had persistent catching pain which is very troubling to him in his capacity as a maintenance technician requiring overhead work. MRI had shown a SLAP lesion from about 12 O’clock to 4 o’clock. We had tried to treat this non-operatively but he had persistent pain and therefore decided to have his shoulder treated surgically. DESCRIPTION OF PROCEDURE: The patient was identified in holding, operative site was marked. He received 2 grams of Ancef IV. SCDs were in place and functioning. He was then brought to the operating room, reidentified, placed supine on the operating room table, and general anesthesia was induced. A time-out was called. He was elevated to a semi-reclining beach chair position using a captain’s table. His head was supported on a padded headrest and his left upper extremity was supported on a padded arm rest. His right shoulder and upper extremity were then prepped and draped in the usual sterile fashion. 60 mL of lactated Ringer’s was injected into the glenohumeral joint. A posterior portal was made 2 cm inferomedial to the posterior lateral
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