Hi list,
I have 13131 & 64831 but I am at a loss of what else to code.
Any suggestions are greatly appreciated!
Melissa Bedford,CCS,CPC
DIAGNOSIS:
1. Left palm complex laceration with long finger digital nerve laceration
POSTOP DIAGNOSIS:
1. Left long finger radial digital nerve laceration
2. Left long finger open proximal phalanx fracture
3. Left long finger interosseous tendon laceration
4. Left long finger radial collateral ligament laceration
PROCEDURE:
1. Wound exploration/I&D/closure 2 cm Left long finger complex laceration
2. Repair Left long finger radial digital nerve
3. Left long finger interosseous tendon repair
4. Left long finger Radial collateral ligament repair
5. I&D left long finger open proximal phalanx fracture
ASSISTANT:
ANESTHESIA:
LMA.
TOURNIQUET TIME:
42 minutes.
BLOOD LOSS:
Minimal.
FLUIDS:
Per anesthesia record
OPERATIVE FINDINGS: Complex volar 2 cm laceration in palm at DPFC deep into 2nd web space with complete RDN lac, open grade 2 radial P1 base fx and complete transection of IO tendon and proximal reflection of RCL insertion.
OPERATIVE SUMMARY IN DETAIL:
Following appropriate informed consent, patient identification, and operative limb, the patient was brought to the operating suite where smooth induction of LMA anesthesia was accomplished by Anesthesiology Service and the patient received broad-spectrum IV antibiotic prophylaxis. The Left upper extremity was prepped and draped in the usual sterile fashion. Time-out procedure performed. The limb was exsanguinated with an Esmarch bandage prior to tourniquet inflation to 275 mmHg. A Bruner incision over the Left distal palm and volar 2nd web space was carried out incorporating the traumatic laceration. Blunt dissection was carried down through the subcutaneous tissues. The radial digital nerve was identified and meticulously dissected and mobilized with findings as above. Radial artery and flexor tendons/sheath/pulleys were intact. The nerve ends were excised back to healthy margins and reflected. The laceration extended deep into the 2nd web space nearly to the hand dorsum. The P1 base was exposed and the IO/lumbical tendons lacerated completely. The RCL was subtotally lacerated off the P1 base and reflected proximally.The radial collateral ligament and interosseous tendon were debrided and repaired after the proximal phalangeal base was curetted. The digital nerve was then repaired with 8-0 suture using microsurgical technique under 4.5x Loupe magnification. Excellent primary repair was noted. Tourniquet was let down and the digits were viable and warm x 5. There was no undue bleeding. Hemostasis performed using electrocautery. Nerve repair was stable even with composite extension. The wounds were reapproximated with nonabsorbable sutures and infiltrated with 0.5% Marcaine for perioperative pain relief. Sterile nonadherent dressing and extension block splint was applied with the long finger adducted to the index loosely. The patient was extubated and transported to the recovery area in stable condition. There were no intraoperative complications.
I have 13131 & 64831 but I am at a loss of what else to code.
Any suggestions are greatly appreciated!
Melissa Bedford,CCS,CPC
DIAGNOSIS:
1. Left palm complex laceration with long finger digital nerve laceration
POSTOP DIAGNOSIS:
1. Left long finger radial digital nerve laceration
2. Left long finger open proximal phalanx fracture
3. Left long finger interosseous tendon laceration
4. Left long finger radial collateral ligament laceration
PROCEDURE:
1. Wound exploration/I&D/closure 2 cm Left long finger complex laceration
2. Repair Left long finger radial digital nerve
3. Left long finger interosseous tendon repair
4. Left long finger Radial collateral ligament repair
5. I&D left long finger open proximal phalanx fracture
ASSISTANT:
ANESTHESIA:
LMA.
TOURNIQUET TIME:
42 minutes.
BLOOD LOSS:
Minimal.
FLUIDS:
Per anesthesia record
OPERATIVE FINDINGS: Complex volar 2 cm laceration in palm at DPFC deep into 2nd web space with complete RDN lac, open grade 2 radial P1 base fx and complete transection of IO tendon and proximal reflection of RCL insertion.
OPERATIVE SUMMARY IN DETAIL:
Following appropriate informed consent, patient identification, and operative limb, the patient was brought to the operating suite where smooth induction of LMA anesthesia was accomplished by Anesthesiology Service and the patient received broad-spectrum IV antibiotic prophylaxis. The Left upper extremity was prepped and draped in the usual sterile fashion. Time-out procedure performed. The limb was exsanguinated with an Esmarch bandage prior to tourniquet inflation to 275 mmHg. A Bruner incision over the Left distal palm and volar 2nd web space was carried out incorporating the traumatic laceration. Blunt dissection was carried down through the subcutaneous tissues. The radial digital nerve was identified and meticulously dissected and mobilized with findings as above. Radial artery and flexor tendons/sheath/pulleys were intact. The nerve ends were excised back to healthy margins and reflected. The laceration extended deep into the 2nd web space nearly to the hand dorsum. The P1 base was exposed and the IO/lumbical tendons lacerated completely. The RCL was subtotally lacerated off the P1 base and reflected proximally.The radial collateral ligament and interosseous tendon were debrided and repaired after the proximal phalangeal base was curetted. The digital nerve was then repaired with 8-0 suture using microsurgical technique under 4.5x Loupe magnification. Excellent primary repair was noted. Tourniquet was let down and the digits were viable and warm x 5. There was no undue bleeding. Hemostasis performed using electrocautery. Nerve repair was stable even with composite extension. The wounds were reapproximated with nonabsorbable sutures and infiltrated with 0.5% Marcaine for perioperative pain relief. Sterile nonadherent dressing and extension block splint was applied with the long finger adducted to the index loosely. The patient was extubated and transported to the recovery area in stable condition. There were no intraoperative complications.