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Wiki 27698 Help please.

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sugarjoe

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Lexington, MI
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This is the description in the op report for a Brostrom ligament repair. I am unsure if this is enough to code or does my doc need to specifically state he repaired a ligament. Any help is greatly appreciated as this is all new to me.

Incision made laterally starting at anterolateral portal, extending paralleling the course of the anterior border of the fibula in the junction between the fibula and talus. Skin and subcutaneous tissue divided. The superficial peroneal nerve was identified and preserved. Dissection was carried down to the capsule. Capsule was opened in line with the incision, flaps proximally and distally were developed and then repaired with a combination of 2-0 Ethibond suture in pants-over-vest fashion. Excellent stability was confirmed with manual testing.
 
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The specific ligament repaired needs to be identified in the body of the note. This cannot be "Assumed". Was this is the only procedure performed? Very rare that it would be performed alone.
 
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