Hi list I am still fairly new to Podiatry and am please needing some assistance on how to code this note.
TIA
Melissa BedfordCCS,CPC
PREOPERATIVE DIAGNOSES:
1. Retrocalcaneal exostosis right
2. Calcified Achilles tendon with chronic tendinitis, right
ankle.
POSTOPERATIVE DIAGNOSES:
1. Retrocalcaneal exostosis.
2. Calcified Achilles tendon with chronic tendinitis, right
ankle.
PROCEDURE PERFORMED:
1. Retrocalcaneal exostectomy, right.
2. Achilles tendon debridement with reattachment, right
calcaneus.
ANESTHESIA:
General with anesthesia consultation for preop pain block.
HEMOSTASIS:
Thigh tourniquet at 300 mmHg x72 minutes.
ESTIMATED BLOOD LOSS:
Minimal.
MATERIALS:
1. Arthrex SpeedBridge.
2. 0 Ti-Cron.
3. 2-0 Ti-Cron.
4. 2-0 Vicryl.
5. 3-0 nylon.
INJECTABLES:
20 mL 0.5% Marcaine plain.
COMPLICATIONS:
None.
SPECIMENS:
None.
INDICATIONS:
Mr. XXX is a 36-year-old gentleman seen in outpatient clinic
for persistently painful chronic Achilles tendonitis,
calcifications with retrocalcaneal exostosis, elected for
surgical reduction. Seen in preoperative clinic where consent
was gone over, signed by patient including all risks and
complications. Seen in preoperative holding where interval
H&P was signed, medication reconciliation was performed.
Right lower extremity was marked and all questions answered to
the patient's satisfaction. He was given 2 g of IV Ancef 30
minutes prior to procedure.
PROCEDURE IN DETAIL:
The patient was brought to the operating room. Anesthesia was
administered and then the patient was placed in the prone
position, well-padded on the operating table. The right lower
extremity was prepped and draped in usual aseptic technique,
exsanguinated, tourniquet inflated to 250 mmHg. Timeout was
performed. Incision was placed in the posterior aspect of the
right Achilles in the central line down to an inverted T at
the level of the insertion to the calcaneus, deepened through
subcutaneous tissues. All small bleeders were bovied.
Peritenon was identified and carefully transected to expose
the Achilles tendon, a inverted T incision was placed in the
midline of the Achilles tendon down to the insertion of the
calcaneus and reflected back, the Achilles was adequately
debrided at that time. There was noted to have 2 calcified
midsubstance areas within the Achilles tendon measuring
approximately 10 and 50 mm respectively. These were debrided
out and removed from the field. Attention was then directed
to the posterior aspect of the right calcaneus where the
patient had enlarged retrocalcaneal exostosis. Utilizing
power saw, this was resected. Osteotomes were also used to
resect the posterior calcaneal spur. The Haglund's deformity
was also resected at that time. The posterior aspect of the
calcaneus was checked via intraoperative fluoroscopy for
adequate resection, which was achieved, a reciprocating rasp
type bur was used to smoothen the posterior aspect of the
calcaneus, was flushed with copious amounts of saline
solution. At that time, the Arthrex SpeedBridge 2 proximal
anchors were used within the posterior body of the calcaneus
and attached to the inferior surface of the Achilles tendon,
then reapproximation of the Achilles tendon was performed with
0 Ti-Cron. Once this was in the midline, was sutured
completely and 2 secondary distal anchors were placed in the
posterior body of the calcaneus and fastened to the FiberWire
anchors for adequate positioning of the calcaneus under mild
tension with complete reattachment. The area was flushed with
copious amounts of saline solution and the deep tissues were
reapproximated with a 2-0 Vicryl. Some additional FiberWire
was also used to attach the most distal segment of the
Achilles tendon also. The peritenon was reapproximated with
2-0 Vicryl and the skin was reapproximated with a 3-0 nylon.
Postop injection was administered, tourniquet deflated,
immediate perfusion noted to the foot. Compressive bandage
was applied. The patient was placed into a posterior splint,
awoken and brought to recovery room where he will remain until
stable. I will see him appropriately in postoperative clinic
TIA
Melissa BedfordCCS,CPC
PREOPERATIVE DIAGNOSES:
1. Retrocalcaneal exostosis right
2. Calcified Achilles tendon with chronic tendinitis, right
ankle.
POSTOPERATIVE DIAGNOSES:
1. Retrocalcaneal exostosis.
2. Calcified Achilles tendon with chronic tendinitis, right
ankle.
PROCEDURE PERFORMED:
1. Retrocalcaneal exostectomy, right.
2. Achilles tendon debridement with reattachment, right
calcaneus.
ANESTHESIA:
General with anesthesia consultation for preop pain block.
HEMOSTASIS:
Thigh tourniquet at 300 mmHg x72 minutes.
ESTIMATED BLOOD LOSS:
Minimal.
MATERIALS:
1. Arthrex SpeedBridge.
2. 0 Ti-Cron.
3. 2-0 Ti-Cron.
4. 2-0 Vicryl.
5. 3-0 nylon.
INJECTABLES:
20 mL 0.5% Marcaine plain.
COMPLICATIONS:
None.
SPECIMENS:
None.
INDICATIONS:
Mr. XXX is a 36-year-old gentleman seen in outpatient clinic
for persistently painful chronic Achilles tendonitis,
calcifications with retrocalcaneal exostosis, elected for
surgical reduction. Seen in preoperative clinic where consent
was gone over, signed by patient including all risks and
complications. Seen in preoperative holding where interval
H&P was signed, medication reconciliation was performed.
Right lower extremity was marked and all questions answered to
the patient's satisfaction. He was given 2 g of IV Ancef 30
minutes prior to procedure.
PROCEDURE IN DETAIL:
The patient was brought to the operating room. Anesthesia was
administered and then the patient was placed in the prone
position, well-padded on the operating table. The right lower
extremity was prepped and draped in usual aseptic technique,
exsanguinated, tourniquet inflated to 250 mmHg. Timeout was
performed. Incision was placed in the posterior aspect of the
right Achilles in the central line down to an inverted T at
the level of the insertion to the calcaneus, deepened through
subcutaneous tissues. All small bleeders were bovied.
Peritenon was identified and carefully transected to expose
the Achilles tendon, a inverted T incision was placed in the
midline of the Achilles tendon down to the insertion of the
calcaneus and reflected back, the Achilles was adequately
debrided at that time. There was noted to have 2 calcified
midsubstance areas within the Achilles tendon measuring
approximately 10 and 50 mm respectively. These were debrided
out and removed from the field. Attention was then directed
to the posterior aspect of the right calcaneus where the
patient had enlarged retrocalcaneal exostosis. Utilizing
power saw, this was resected. Osteotomes were also used to
resect the posterior calcaneal spur. The Haglund's deformity
was also resected at that time. The posterior aspect of the
calcaneus was checked via intraoperative fluoroscopy for
adequate resection, which was achieved, a reciprocating rasp
type bur was used to smoothen the posterior aspect of the
calcaneus, was flushed with copious amounts of saline
solution. At that time, the Arthrex SpeedBridge 2 proximal
anchors were used within the posterior body of the calcaneus
and attached to the inferior surface of the Achilles tendon,
then reapproximation of the Achilles tendon was performed with
0 Ti-Cron. Once this was in the midline, was sutured
completely and 2 secondary distal anchors were placed in the
posterior body of the calcaneus and fastened to the FiberWire
anchors for adequate positioning of the calcaneus under mild
tension with complete reattachment. The area was flushed with
copious amounts of saline solution and the deep tissues were
reapproximated with a 2-0 Vicryl. Some additional FiberWire
was also used to attach the most distal segment of the
Achilles tendon also. The peritenon was reapproximated with
2-0 Vicryl and the skin was reapproximated with a 3-0 nylon.
Postop injection was administered, tourniquet deflated,
immediate perfusion noted to the foot. Compressive bandage
was applied. The patient was placed into a posterior splint,
awoken and brought to recovery room where he will remain until
stable. I will see him appropriately in postoperative clinic