Case # 6 clinical added for Answer key & Rationale
Case # 6 clinical added for Answer key & Rationale
Since the clinical info wasn't included in posting of answer & rationale; and the link to case clinical info given now is not accessible (error page shows up) .... I thought it wise to include the missing clinical info.
ANSWER KEY
CPT: 23615, 20690, 27825, 27788
CPT Modifiers: LT, RT, RT, RT
ICD-9: 812.00, 831.02, 824.8, 824.2
RATIONALE
The provider treats the left proximal humerus fracture with an open reduction and internal fixation. The fracture is closed. When a fracture and dislocation occur at the same anatomic site, only report a
diagnosis code for the fracture.
The provider also treats the distal tibia fracture by reducing the distal tibia and lateral malleolar fractures and applying a uniplane external fixator. A code is reported for the closed treatment with manipulation of the distal tibia as well as the lateral malleolar fractures.
CPT: 23615-LT, 20690-RT, 27825-RT, 27788-RT or 23615-LT, 20690-RT, 27825-RT
Steps to look up: Fracture/Humerus/Open Treatment; Application/Bone Fixation Device/Uniplane; Fracture/Tibia/Distal; Fracture/Ankle/Lateral.
Credit for answers that did not include 27788 because the documentation was not clear if both the tibia and lateral malleolar fractures were reduced. It is stated in the header but in the body of the note is stated reduction without specifying both sites.
ICD-9-CM: 812.00, 824.8, 824.2
Steps to look up: Fracture/humerus/upper end or extremity; Fracture/tibia/distal end; Fracture/malleolus/lateral
Diagnosis codes 812.00, 824.8 as an acceptable answer because 824.8 does include the ankle. Because the lateral malleolar fracture is documented, for proper coding it should be coded separately.
Hint: The next case #6 involves injuries to more than one part of a 31 year old patient and requires surgery. CCI Edits, modifiers, and even ICD-10 knowledge will be helpful!
Case #6
PREOPERATIVE DIAGNOSES:
1.Comminuted left proximal humerus fracture with posterior head dislocation.
2.Mildly displaced distal tibial fracture with extension into the tibial plafond and comminuted lateral malleolus fracture.
POSTOPERATIVE DIAGNOSES:
1. Comminuted left proximal humerus fracture with posterior head dislocation .
2. Mildy displaced distal tibial fracture with extension into the tibial plafond and comminuted lateral malleolus fracture.
PROCEDURE:
1.Open reduction internal fixation (ORIF) of left proximal humerus fracture using Synthes proximal locking plate with 10 cc of musculoskeletal transplant foundation DBX mix.
2.Application of Synthes external fixator from tibia to calcaneus and talar neck with closed reduction of distal tibia and lateral malleolar fractures.
Anesthesia: General Endotracheal
Estimated Blood Loss: 300 cc
Drains: 1/8-inch Hemovac left shoulder
Tourniquet: Not used
Complications: None
Pertinent History: Patient is a 31-year-old male who sustained the above injuries. Plain radiographs and CT scan confirmed a severe fracture/dislocation of his left shoulder with a fairly small humeral head fragment. Given his young age, he presents for urgent open reduction internal fixation (ORIF) of his proximal humerus fracture. He will also undergo application of an external fixator for his right ankle fracture.
Description of Procedure: After informed consent was obtained, the patient was transported to the Operating Room and placed in a comfortable supine position. Following the induction of general endotracheal anesthesia, the left shoulder and arm were prepped and draped in the usual sterile fashion, as well as the right leg. While the patient was being positioned for the shoulder surgery, two stab incisions were made along the medial border of the tibial shaft below the proximal tibial fracture. Two stab incisions were made overlying the foot, one over the calcaneal tuberosity and the other over the talar neck. Schanz pins were placed with good purchase of bone. C-arm was used to verify good placement of all screws. An outrigger device was placed and the Synthes large external fixator was fashioned in a triangular configuration. A reduction was performed and the external fixator was tightened. There was noted to be adequate alignment of the fracture sized with good stability. Next, an incision was made along the left shoulder extending from near the AC joint to the anterior aspect of the proximal arm. Dissection was carried down to the deltopectoral interval. The cephalic vein was identified and retracted laterally with the deltoid. A small portion of the pectoralis tendon was incised.
The fracture was severely comminuted and markedly displaced. Traction was applied. Bursa was excised as needed. There was a rent noted from the traumatic injury between the supraspinatus and infraspinatus. Scissors were used to dissect the interval between these two tendons to better expose the humeral head, which was posteriorly dislocated and locked in that position by the glenoid. Careful dissection was performed to remove the humeral head from this position. The head was then centered into the glenoid. The Synthes humeral locking plate was then applied to the appropriate level and secured to the shaft with a single screw. The outrigger device was used to place multiple screws into the humeral head. Unfortunately, this was a fairly thin fragment of the humeral head, but given his young age I made all attempts to provide as much rigid fixation as possible to try to get this to heal. He is at high risk of a vascular necrosis, however. The C-arm was used to verify good placement of the screws. The remaining two locking screws were placed into the humeral shaft. The shoulder was taken through range of motion and there was noted to be good stability with the humeral head moving as a unit with the shaft. There was a fairly large void at the fracture. The wound was irrigated with saline. This void was filled with 10 cc DBX mix. The tuberosities were then repaired to each other and to the plate using a combination of #2 Fiberwire and interrupted #1 Ethibond sutures. This construct was felt to be stable. A 1/8-inch Hemovac drain was placed. The wound was irrigated with saline. The deltopectoral interval was approximated loosely with a #1 Ethibond suture. The subcutaneous structures were approximated with inerrupted 2-0 Vicryl suture. The skin was approximated with staples. Xeroform and 4 x 4 gauze were applied and secured with tape. He was placed into a shoulder immobilizer and transported to the Recovery Room in stable condition having tolerated the procedure well.
