I was told this case study 3 diagnosis codes and 2 procedure codes I still can't find at.

Outpatient Surgery
Patient Case Number: OPSX34-Clerk, Solomon
Patient Name: Solomon Clerk	DOB: 08-08-74	Sex: M
Date of Service: 04-17-XX	Surgeon: Adrian Michaels, MD
Pre-Operative Diagnosis R/o torn rotator cuff, right shoulder	Post-Operative Diagnosis Rotator cuff tear, right shoulder. Impingement syndrome w/ rotator cuff tear. Bursitis, right shoulder.
Procedure Performed: Arthroscopic acromioplasty w/ rotator cuff repair
Anesthesia: General	Complications: None

Operative Procedure:

The patient was identified in the preoperative area. Proper surgical site protocol was followed. He was subsequently taken to the operating suite where a general anesthetic was administered by the department of anesthesia. The patient was carefully positioned in the beach chair position. All bony prominences were well padded. The right shoulder and arm were sterilely prepped and draped in the usual manner.

Bony landmarks were identified and arthroscopic portals infiltrated with 1% Xylocaine with epinephrine. Posterior portal to the glenohumeral joint was established in a standard fashion. An accessory anterior portal was established under triangulation techniques and a probe and shaver inserted anteriorly. There is some fraying of the biceps tendon, but the anchor itself was intact. There is an area of erosion in the glenoid, the anterior labrum is intact. The humeral head appears satisfactory.

Examination of the rotator cuff demonstrates a large area of tearing laterally. The bare spot is quite evident.

At this point, the arthroscope was reinserted posteriorly into the subacromial space. Moderate bursitis was present and bursectomy performed through a lateral portal. The rotator cuff tear was identified and noted to be quite large, easily mobile. I then proceeded with a standard anterior-inferior acromioplasty. The patient does have an os acromiale and we did not disrupt this area between the anterior process in the body of the acromion. Following the completion of the acromioplasty, all arthroscopic instruments removed and I made a lateral incision extending from the lateral aspect of the acromion laterally. The deltoid fascia was incised and blunt dissection through the deltoid muscle to the subacromial space was performed. Retractors were inserted.

Excellent exposure of the cuff tear was present. There is a full-thickness non-retracted supra and infraspinatus tear. The footprint was identified and cleared of all debris and soft tissue. I debrided the lateral edge of the rotator cuff and utilized 3 medial row Arthrex corkscrews followed by 2 lateral row Push locks for double row fixation.

Excellent apposition of the repair was present and palpation on the undersurface of the acromion and clavicle was satisfactory for no evidence of impingement. The wound was copiously irrigated of all debris and closed in a routine fashion. Sterile compressive dressings were applied. A sling and swathe was applied. The patient returned to recovery cart in satisfactory condition having tolerated the procedure well.

Electronically Signed By: Adrian Michaels, MD

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