Surgical Notes

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Patient Details

General Surgical Notes

Date

Place of Service

select..

Side

Procedure

Position

Beach Chair Lateral Decibutis Lateral Traction

Anaesthetist

Dr L Mostert Dr H Peyper Dr M Reyneke Dr J Sadzik Dr R Spies Other

Medication Administered

Authorization Number

Referring Doctor

Referring Dr Practice Number

ICD-10 Confirmation

Primary ICD-10

select.. 209.0 - Flu after 210.0 - Consultations G54.0 - Brachial Plexus M00.01 - Staphylococcal arthritis, shoulder M10.01 - Idiopathic gout, shoulder region M19.0 - Osteoarthritis -M19.0 M19.01 - Osteoarthritis Primary M19.1 - Osteoarthritis Post Trauma -M19.1 M24.21 - Disorder of ligament, shoulder region M24.41 - Laterjet M24.51 - Contracture of joint M25.21 - Flail joint M25.31 - Other instability of joint M25.41 - Effusion of joint M25.52 - Pain in joint, upper arm M25.71 - Osteophyte M25.91 - Joint disorder M54.22 - Cervicle Spine M61.01 - Myositis ossificans traumatica M61.21 - Paralytic calcification and ossification of muscle M61.411 - Other calcification of muscles - Shoulder M62.31 - Immobility syndrome (paraplegic) M62.41 - Contracture of muscle M62.51 - Muscle wasting and atrophy M62.61 - Muscle strain M65.01 - Abscess of tendon sheath M65.11 - Other infective (teno)synovitis M65.81 - Other synovitis and tenosynovitis M65.91 - Synovitis and tenosynovitis M66.41 - Spontaneous rupture of other tendons M70.22 - Olecranon bursitis, upper arm M70.81 - Other soft tissue disorders related to use, overuse and pressure M71.01 - Abscess of bursa M71.11 - Other infective bursitis M73.81* - Other soft tissue disorders M74.5 - M74.5 M75.0 - Adhesive capsulitis M75.1 - Rotator cuff syndrome M75.2 - Bicipital tendinitis M75.3 - Calcific tendinitis M75.4 - Impingement syndrome M75.5 - Bursitis M75.8 - Other shoulder lesions M75.9 - Shoulder lesion, uspecified M77.12 - Lateral epicondylitis M79.01 - Rheumatism M79.11 - Myalgia, shoulder region M79.21 - Neuralgia and neuritis M79.51 - Residual foreign body in soft tissue M79.61 - Pain in limb M80.01 - Postmenopausal osteoporosis with pathological fracture M80.21 - Osteoporosis of disuse with pathological fracture M80.81 - Other osteoporosis with pathological fracture M81.01 - Postmenopausal osteoporosis M86.31 - Chronic multifocal osteomyelitis M86.41 - Chronic osteomyelitis with draining sinus M87.11 - Osteonecrosis due to drugs M87.21 - Osteonecrosis due to previous trauma M87.31 - Other secondary osteonecrosis M90.71* - Fracture of bone in neoplastic disease (C00 M94.31 - Chondrolysis M94.91 - Disorder of cartilage M96.6 - Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate 93.6 - 93.6 S40 - Superficial injury of shoulder and upper arm S40.0 - Contusion of shoulder and upper arm S41.0 - Open wound S42 - Fracture of shoulder and upper arm S42.0 - Fracture of clavicle S42.00 - Fracture of clavicle, closed S42.01 - Fracture of clavicle, open S42.1 - Fracture of scapula S42.10 - Fracture of scapula, closed S42.11 - Fracture of scapula, open S42.2 - Fracture of upper end of humerus S42.20 - Fracture of upper end of humerus, closed S42.21 - Fracture of upper end of humerus, open S42.3 - Fracture of shaft of humerus S42.30 - Fracture of shaft of humerus, closed S42.31 - Fracture of shaft of humerus, open S42.7 - Multiple fractures of clavicle, scapula and humerus S42.70 - Multiple fractures of clavicle, scapula and humerus, closed S42.8 - Fracture of other parts of shoulder and upper arm S43 - Dislocation, sprain and strain of joints and ligaments of shoulder S43.0 - Dislocation of shoulder joint S43.1 - Dislocation of acromioclavicular joint S43.2 - Dislocation of sternoclavicular joint S43.4 - Sprain and strain of shoulder joint S43.5 - Sprain and strain of acromioclavicular joint S43.6 - Sprain and strain of sternoclavicular joint S43.7 - Sprain and strain of other and unspecified parts of shoulder girdle S44.1 - Injury of median nerve at upper arm level S44.2 - Injury of radial nerve at upper arm level S44.3 - Injury of axillary nerve S44.4 - Injury of musculocutaneous nerve S44.5 - Injury of cutaneous sensory nerve at shoulder and upper arm level S46 - Injury of muscle and tendon at shoulder and upper arm level S46.0 - Inujry of muscle(s) and tendon(s) of the rotator cuff of shoulder S46.1 - Injury of muscle and tendon of long head of biceps S46.2 - Injury of muscle and tendon of other parts of biceps S46.3 - Injury of muscle and tendon of triceps S46.7 - Trauma - Multiple Tendons S46.80 - Unspecified injury of other muscles, fascia and tendons S52.5 - Fracture of lower end of radius

Secondary ICD-10

209.0 - Flu after 210.0 - Consultations G54.0 - Brachial Plexus M00.01 - Staphylococcal arthritis, shoulder M10.01 - Idiopathic gout, shoulder region M19.0 - Osteoarthritis -M19.0 M19.01 - Osteoarthritis Primary M19.1 - Osteoarthritis Post Trauma -M19.1 M24.21 - Disorder of ligament, shoulder region M24.41 - Laterjet M24.51 - Contracture of joint M25.21 - Flail joint M25.31 - Other instability of joint M25.41 - Effusion of joint M25.52 - Pain in joint, upper arm M25.71 - Osteophyte M25.91 - Joint disorder M54.22 - Cervicle Spine M61.01 - Myositis ossificans traumatica M61.21 - Paralytic calcification and ossification of muscle M61.411 - Other calcification of muscles - Shoulder M62.31 - Immobility syndrome (paraplegic) M62.41 - Contracture of muscle M62.51 - Muscle wasting and atrophy M62.61 - Muscle strain M65.01 - Abscess of tendon sheath M65.11 - Other infective (teno)synovitis M65.81 - Other synovitis and tenosynovitis M65.91 - Synovitis and tenosynovitis M66.41 - Spontaneous rupture of other tendons M70.22 - Olecranon bursitis, upper arm M70.81 - Other soft tissue disorders related to use, overuse and pressure M71.01 - Abscess of bursa M71.11 - Other infective bursitis M73.81* - Other soft tissue disorders M74.5 - M74.5 M75.0 - Adhesive capsulitis M75.1 - Rotator cuff syndrome M75.2 - Bicipital tendinitis M75.3 - Calcific tendinitis M75.4 - Impingement syndrome M75.5 - Bursitis M75.8 - Other shoulder lesions M75.9 - Shoulder lesion, uspecified M77.12 - Lateral epicondylitis M79.01 - Rheumatism M79.11 - Myalgia, shoulder region M79.21 - Neuralgia and neuritis M79.51 - Residual foreign body in soft tissue M79.61 - Pain in limb M80.01 - Postmenopausal osteoporosis with pathological fracture M80.21 - Osteoporosis of disuse with pathological fracture M80.81 - Other osteoporosis with pathological fracture M81.01 - Postmenopausal osteoporosis M86.31 - Chronic multifocal osteomyelitis M86.41 - Chronic osteomyelitis with draining sinus M87.11 - Osteonecrosis due to drugs M87.21 - Osteonecrosis due to previous trauma M87.31 - Other secondary osteonecrosis M90.71* - Fracture of bone in neoplastic disease (C00 M94.31 - Chondrolysis M94.91 - Disorder of cartilage M96.6 - Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate 93.6 - 93.6 S40 - Superficial injury of shoulder and upper arm S40.0 - Contusion of shoulder and upper arm S41.0 - Open wound S42 - Fracture of shoulder and upper arm S42.0 - Fracture of clavicle S42.00 - Fracture of clavicle, closed S42.01 - Fracture of clavicle, open S42.1 - Fracture of scapula S42.10 - Fracture of scapula, closed S42.11 - Fracture of scapula, open S42.2 - Fracture of upper end of humerus S42.20 - Fracture of upper end of humerus, closed S42.21 - Fracture of upper end of humerus, open S42.3 - Fracture of shaft of humerus S42.30 - Fracture of shaft of humerus, closed S42.31 - Fracture of shaft of humerus, open S42.7 - Multiple fractures of clavicle, scapula and humerus S42.70 - Multiple fractures of clavicle, scapula and humerus, closed S42.8 - Fracture of other parts of shoulder and upper arm S43 - Dislocation, sprain and strain of joints and ligaments of shoulder S43.0 - Dislocation of shoulder joint S43.1 - Dislocation of acromioclavicular joint S43.2 - Dislocation of sternoclavicular joint S43.4 - Sprain and strain of shoulder joint S43.5 - Sprain and strain of acromioclavicular joint S43.6 - Sprain and strain of sternoclavicular joint S43.7 - Sprain and strain of other and unspecified parts of shoulder girdle S44.1 - Injury of median nerve at upper arm level S44.2 - Injury of radial nerve at upper arm level S44.3 - Injury of axillary nerve S44.4 - Injury of musculocutaneous nerve S44.5 - Injury of cutaneous sensory nerve at shoulder and upper arm level S46 - Injury of muscle and tendon at shoulder and upper arm level S46.0 - Inujry of muscle(s) and tendon(s) of the rotator cuff of shoulder S46.1 - Injury of muscle and tendon of long head of biceps S46.2 - Injury of muscle and tendon of other parts of biceps S46.3 - Injury of muscle and tendon of triceps S46.7 - Trauma - Multiple Tendons S46.80 - Unspecified injury of other muscles, fascia and tendons S52.5 - Fracture of lower end of radius

External Cause Code

Modifier Confirmation

0009 - Assistant Fee 20%

Assistant

select.. Badenhorst Crafford Rainsford Heyns Storm

Registration Number

Surname

0018 - BMI > 50

Height (cm)

Weight (kg)

0011 - Emergency Procedure

Time (In Minutes)

0014 - Revision

0008 - Specialist Assistant

Assistant

select.. Badenhorst Crafford Rainsford Heyns Storm

Registration Number

Surname

Other (If Applicable)

recId	Procedure Code	Procedure Description	Tendon	Delete

Biceps

Biceps Diagnostic

SBSC

SBSC Diagnostic

RTC

RTC Diagnositc

Humeral Head

Humeral Head Diagnostic

Capsule

Capsule Diagnostic

Synovium

Synovium Diagnostic

Glenoid

Glenoid Diagnostic

Rotator Cuff

Rotator Cuff Diagnostic

Bursa

Bursa Diagnostic

Acromion

Acromion Diagnostic

CA Ligament

CA Ligament Diagnostic

ACJ

ACJ Diagnostic

Biceps

Biceps Procedures Done

SBSC

SBSC Procedures Done

RTC

PASTA

Repair

Tendon Quality

Muscle Quality

Other RTC Procedures

Cuff

Humeral Head

Humeral Head Procedures Done

Joint Debridement

Joint Debridement Procedures Done

Capsule

Capsule Procedures Done

Synovium

Synovium Procedures Done

Glenoid

Glenoid Procedures Done

Acromion

Acromion Procedures Done

Bursa

Bursa Procedures Done

Coracoid

Coracoid Procedures Done

ACJ

ACJ Procedures Done

Notes

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Open Surgery

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Shoulder Arthroscopy Image

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Surgical Attachments

Billing

Link to User