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Wiki CPT to Remove loose fragment from ankle

RebeccaMoney

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I know this has been asked several times. Which CPT? Deltoid ligament repair and osteotomy also being done. There was no arthrotomy done so I can't figure out what CPT. Here is a section of the operative report showing the loose fragment being removed.
PROCEDURE DETAILS: .......Incision then place over the medial aspect of the ankle in a longitudinal fashion. Superficial veins ligated with electrocautery. The superficial deltoid ligaments removed from the medial malleolus in a cuffed pattern. Deeper dissection reveleaed a loose fragment within the superficial area and a small portion of the deep deltoid. This was sharply excised. The deltoid was repaired using a fiber tack suture.
Would you consider the loose fragment as just incident to the deltoid repair? Any help is much appreciated.
Thank you,
 
It is helpful with surgical questions to post all the procedures that were done and the diagnosis at a minimum. It's hard to say without more info. Was there a fracture of the medial malleolus and fragments from that were in the ligament? Why did they do an osteotomy? It may or may not be reportable depending on what else was done. If there was ORIF of the med mal it includes removal of fracture fragments or LB. Was the osteotomy for deformity correction?
 
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