Requesting assistance due to.provider cpt code selection. What CPT code and diagnosis code selection would be selected for this operative note?
PREOPERATIVE DIAGNOSIS: Right small finger, displaced/angulated Salter Harris 2 fracture of proximal phalanx
POSTOPERATIVE DIAGNOSIS: Right small finger, displaced/angulated Salter Harris 2 fracture of proximal phalanx
PROCEDURE PERFORMED: Right small finger closed reduction and percutaneous pinning of proximal phalanx growth plate fracture
SURGEON:
ASSISTANT: She assisted with patient positioning and soft tissue retraction and protection of neurovascular
structures
ANTIBIOTICS: weight based Ancef
ESTIMATED BLOOD LOSS: 5 mL
ANESTHESIA: General.
SPECIMEN: None.
COMPLICATIONS: None.
INDICATIONS FOR SURGERY: This is a 8-year-old patient who sustained a Salter Harris 2 fracture of the right small finger. It was fractured at the base of the proximal phalanx with extension in the growth. Closed reduction did not produce an adequate enough reduction There was angulation in both the AP / lateral planes. We discussed fracture reduction and possible pinning through surgical intervention.
All the risks, benefits, and alternatives of surgery were discussed. Risks of surgery include, but not limited to bleeding, infection, damage to
surrounding blood vessels and nerves, risk of nonhealing of the fracture fragment, risk of persistent instability or subluxation, and risk of
anesthesia, and risk for needing additional surgeries. Patient and family both elected to proceed.
OPERATIVE DETAIL: The patient was seen and marked in the preoperative area. History and physical updated. Consent was reconfirmed. Was seen by Anesthesia. Was taken to OR, prepped, draped and positioned in the usual sterile fashion. Antibiotics was given prior to incision. Was supine on the arm table, mini C-arm and for x-rays intraoperatively.
Timeout was called.
Please note that this report contains the most accurate documentation and results as of the date and time listed below.
I started by reducing the right small finger under live fluoroscopy. I was able to get a good reduction with flexion of MCP joint and radially directed force and then hold that stable. Under live fluoro, there was minimal force required to re-dislocate. So, decision to use pin was made intraoperatively. I re-reduced the fracture with the same maneuver described above. Then, I placed one 0.035 mm K-wire from the base of the proximal phalanx into the main shaft fracture fragment. I fired this down central axis with fracture and SH2 fracture reduced. This was to my liking. I then fired another 2nd pin into the fracture fragment. So in all 2 pins were placed under direct visualization and direct guidance under fluoroscopy. This gave a good secure fixation. I tested and ranged the motion of the thumb at the MP and IP joint. There was no residual subluxation. I was happy with my placement. I then cut the pins shorter. I placed pin caps over the pins to cap them.
I then made a slight opening along the incisions of the skin, but not tethered to each of the pins. I then placed Xeroform around the pins and then placed them into a well padded bulky soft thumb spica splint. IP joint is free. Was subsequently awoken from anesthesia and transferred to the PACU in stable condition.
POSTOPERATIVE: The patient will be in the short arm splint until patient sees me next week and then I will transition into a cast. I told family to expect to be immobilized for about 6 weeks postoperatively. I then will pull the pin out typically 4-5 weeks postop. We will need to follow him periodically with x-rays to make sure that the fracture stays reduced and that the joint does not resubluxate. Patient was given pain medications. No chemoprophylaxis for DVT is necessary. I will see back in 1 week.
PREOPERATIVE DIAGNOSIS: Right small finger, displaced/angulated Salter Harris 2 fracture of proximal phalanx
POSTOPERATIVE DIAGNOSIS: Right small finger, displaced/angulated Salter Harris 2 fracture of proximal phalanx
PROCEDURE PERFORMED: Right small finger closed reduction and percutaneous pinning of proximal phalanx growth plate fracture
SURGEON:
ASSISTANT: She assisted with patient positioning and soft tissue retraction and protection of neurovascular
structures
ANTIBIOTICS: weight based Ancef
ESTIMATED BLOOD LOSS: 5 mL
ANESTHESIA: General.
SPECIMEN: None.
COMPLICATIONS: None.
INDICATIONS FOR SURGERY: This is a 8-year-old patient who sustained a Salter Harris 2 fracture of the right small finger. It was fractured at the base of the proximal phalanx with extension in the growth. Closed reduction did not produce an adequate enough reduction There was angulation in both the AP / lateral planes. We discussed fracture reduction and possible pinning through surgical intervention.
All the risks, benefits, and alternatives of surgery were discussed. Risks of surgery include, but not limited to bleeding, infection, damage to
surrounding blood vessels and nerves, risk of nonhealing of the fracture fragment, risk of persistent instability or subluxation, and risk of
anesthesia, and risk for needing additional surgeries. Patient and family both elected to proceed.
OPERATIVE DETAIL: The patient was seen and marked in the preoperative area. History and physical updated. Consent was reconfirmed. Was seen by Anesthesia. Was taken to OR, prepped, draped and positioned in the usual sterile fashion. Antibiotics was given prior to incision. Was supine on the arm table, mini C-arm and for x-rays intraoperatively.
Timeout was called.
Please note that this report contains the most accurate documentation and results as of the date and time listed below.
I started by reducing the right small finger under live fluoroscopy. I was able to get a good reduction with flexion of MCP joint and radially directed force and then hold that stable. Under live fluoro, there was minimal force required to re-dislocate. So, decision to use pin was made intraoperatively. I re-reduced the fracture with the same maneuver described above. Then, I placed one 0.035 mm K-wire from the base of the proximal phalanx into the main shaft fracture fragment. I fired this down central axis with fracture and SH2 fracture reduced. This was to my liking. I then fired another 2nd pin into the fracture fragment. So in all 2 pins were placed under direct visualization and direct guidance under fluoroscopy. This gave a good secure fixation. I tested and ranged the motion of the thumb at the MP and IP joint. There was no residual subluxation. I was happy with my placement. I then cut the pins shorter. I placed pin caps over the pins to cap them.
I then made a slight opening along the incisions of the skin, but not tethered to each of the pins. I then placed Xeroform around the pins and then placed them into a well padded bulky soft thumb spica splint. IP joint is free. Was subsequently awoken from anesthesia and transferred to the PACU in stable condition.
POSTOPERATIVE: The patient will be in the short arm splint until patient sees me next week and then I will transition into a cast. I told family to expect to be immobilized for about 6 weeks postoperatively. I then will pull the pin out typically 4-5 weeks postop. We will need to follow him periodically with x-rays to make sure that the fracture stays reduced and that the joint does not resubluxate. Patient was given pain medications. No chemoprophylaxis for DVT is necessary. I will see back in 1 week.