Hi list,
I am still fairly new to coding surgeries and am needing some input on how others would code this case, please.
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS(ES):
Open wound, right hand with extensor tendon involvement.
POSTOPERATIVE DIAGNOSIS(ES):
Open wound, right hand with extensor tendon involvement.
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Irrigation and debridement of skin, subcutaneous tissue, and
damaged tendon, right hand.
2. Irrigation and debridement of right long finger traumatic
arthrotomy at metacarpophalangeal joint.
3. Right hand and long finger extensor tendon repair.
ANESTHESIA:
Regional; MAC.
FLUID:
300 mL.
ESTIMATED BLOOD LOSS:
Less than 20 mL.
TOURNIQUET TIME:
20 minutes.
COMPLICATIONS:
None apparent.
SUMMARY:
The patient received the block and was brought to the operative
room, placed on table supine position, IV antibiotics and
sedation was administered. Pneumatic tourniquet placed on right
upper extremity. The right arm was prepped and draped in a
sterile manner. An intraoperative time-out was performed
identifying the patient, operative plan, limb was exsanguinated,
pneumatic tourniquet inflated. The patient's skin laceration of
the long finger and metacarpophalangeal joint was extended both
proximally and distally. Careful dissection was carried out
through subcutaneous tissue down to the level of extensor
mechanism, which there was a full-thickness complete laceration
just at the proximal edge of the sagittal bands. The tendons
were sharply debrided and freshened up conservatively. There was
also a traumatic arthrotomy as well as a laceration to the
cartilage surface of the long finger metacarpal head. It was
about 5 mm in length an obliquely oriented. There were no loose
bodies in the joint. There is no purulence encounter. The wound
was copiously irrigated, and then sharp debridement of
contaminated tissue was performed. The joint was copiously
irrigated. The joint capsule was then addressed. It was
repaired with Polysorb suture. Using 3 separate horizontal
mattress stitches and using a nonabsorbable suture material, the
extensor tendon was repaired end-to-end. It was under no undue
tension. Once the tendon was repaired, normal cascade returned
to the fingers, tenodesis testing by flexing and extending the
wrist did not compromise the extensor tendon repair and passive
deep flexion of the proximal and distal interphalangeal joints
also did not compromise the extensor tendon repair. The wound
was copiously irrigated. The pneumatic tourniquet was deflated.
Bipolar cautery was used to achieve adequate hemostasis. Once
again, the wound was irrigated. The skin edges reapproximated
with 4-0 monofilament. Sterile dressing and splint was applied.
All sharp and sponge counts were correct. There were no apparent
complications during the procedure.
DISPOSITION:
Patient will be given a prescription for pain medicine, as well
as 7-day additional course of antibiotics for his traumatic
arthrotomy as prophylaxis. He will return to clinic in 10 to 14
days to begin for wound check and to begin formal occupational
therapy for extensor tendon repair protocol.
I am still fairly new to coding surgeries and am needing some input on how others would code this case, please.
TIA
MB,CCS,CPC
PREOPERATIVE DIAGNOSIS(ES):
Open wound, right hand with extensor tendon involvement.
POSTOPERATIVE DIAGNOSIS(ES):
Open wound, right hand with extensor tendon involvement.
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Irrigation and debridement of skin, subcutaneous tissue, and
damaged tendon, right hand.
2. Irrigation and debridement of right long finger traumatic
arthrotomy at metacarpophalangeal joint.
3. Right hand and long finger extensor tendon repair.
ANESTHESIA:
Regional; MAC.
FLUID:
300 mL.
ESTIMATED BLOOD LOSS:
Less than 20 mL.
TOURNIQUET TIME:
20 minutes.
COMPLICATIONS:
None apparent.
SUMMARY:
The patient received the block and was brought to the operative
room, placed on table supine position, IV antibiotics and
sedation was administered. Pneumatic tourniquet placed on right
upper extremity. The right arm was prepped and draped in a
sterile manner. An intraoperative time-out was performed
identifying the patient, operative plan, limb was exsanguinated,
pneumatic tourniquet inflated. The patient's skin laceration of
the long finger and metacarpophalangeal joint was extended both
proximally and distally. Careful dissection was carried out
through subcutaneous tissue down to the level of extensor
mechanism, which there was a full-thickness complete laceration
just at the proximal edge of the sagittal bands. The tendons
were sharply debrided and freshened up conservatively. There was
also a traumatic arthrotomy as well as a laceration to the
cartilage surface of the long finger metacarpal head. It was
about 5 mm in length an obliquely oriented. There were no loose
bodies in the joint. There is no purulence encounter. The wound
was copiously irrigated, and then sharp debridement of
contaminated tissue was performed. The joint was copiously
irrigated. The joint capsule was then addressed. It was
repaired with Polysorb suture. Using 3 separate horizontal
mattress stitches and using a nonabsorbable suture material, the
extensor tendon was repaired end-to-end. It was under no undue
tension. Once the tendon was repaired, normal cascade returned
to the fingers, tenodesis testing by flexing and extending the
wrist did not compromise the extensor tendon repair and passive
deep flexion of the proximal and distal interphalangeal joints
also did not compromise the extensor tendon repair. The wound
was copiously irrigated. The pneumatic tourniquet was deflated.
Bipolar cautery was used to achieve adequate hemostasis. Once
again, the wound was irrigated. The skin edges reapproximated
with 4-0 monofilament. Sterile dressing and splint was applied.
All sharp and sponge counts were correct. There were no apparent
complications during the procedure.
DISPOSITION:
Patient will be given a prescription for pain medicine, as well
as 7-day additional course of antibiotics for his traumatic
arthrotomy as prophylaxis. He will return to clinic in 10 to 14
days to begin for wound check and to begin formal occupational
therapy for extensor tendon repair protocol.