Could someone let me know if I am heading in the right direction with this op report. I am not sure on this procedure. I have a hard time with the foot region.
Postoperative diagnosis: Left peroneal tenosynovitis with peroneus longus tendon tear.
Procedure: Debridement of the left peroneal tendons with peroneus longus tendon tear repair.
Details of procedure: planned and marked an incision over the peroneal tendons starting proximal to the distal fibula extending around the tip of the fibula down towards the base of the fifth metatarsal. An Esmarch was used to exsanguinate the patients limb and the tourniquet was inflated. A scalpel was used to incise the skin as marked. Pickup and scissors were used to continue dissection through the subcutaneous tissues. I identified the sural nerve and protected it throughout the procedure. I dissected down to the peroneal tendon sheath. I opened the sheath with a knife and scissor taking great care to protect the underlying tendon. With the tendons divided into separate sheaths, I open both tendon sheaths. I examined the peroneus longus, there was some synovitis, which I debrided with a pickup and scissor. I then examined the peroneus longus tendon. I identified the tear as well as some degenerative portions of the tendon. I also debrided the synovitic tissue on the tendon. At this point, I repaired the tear in the region in which I had removed degenerative tendon with a Vicryl suture. I then thoroughly irrigated the wound. I repaired the superior peroneal retinaculum with Vicryl up to the ankle through a range of motion. The tendons tracked nicely behind the fibula. The wound was throughly irrigated with copious amounts of sterile saline and attention was turned to closure.....
I was thinking of using 27665, but would I list it just once or twice with a -59 modifier. Someone had mentioned to look at 27675, but not sure on that one either.
Thanks in advance for your input!
Postoperative diagnosis: Left peroneal tenosynovitis with peroneus longus tendon tear.
Procedure: Debridement of the left peroneal tendons with peroneus longus tendon tear repair.
Details of procedure: planned and marked an incision over the peroneal tendons starting proximal to the distal fibula extending around the tip of the fibula down towards the base of the fifth metatarsal. An Esmarch was used to exsanguinate the patients limb and the tourniquet was inflated. A scalpel was used to incise the skin as marked. Pickup and scissors were used to continue dissection through the subcutaneous tissues. I identified the sural nerve and protected it throughout the procedure. I dissected down to the peroneal tendon sheath. I opened the sheath with a knife and scissor taking great care to protect the underlying tendon. With the tendons divided into separate sheaths, I open both tendon sheaths. I examined the peroneus longus, there was some synovitis, which I debrided with a pickup and scissor. I then examined the peroneus longus tendon. I identified the tear as well as some degenerative portions of the tendon. I also debrided the synovitic tissue on the tendon. At this point, I repaired the tear in the region in which I had removed degenerative tendon with a Vicryl suture. I then thoroughly irrigated the wound. I repaired the superior peroneal retinaculum with Vicryl up to the ankle through a range of motion. The tendons tracked nicely behind the fibula. The wound was throughly irrigated with copious amounts of sterile saline and attention was turned to closure.....
I was thinking of using 27665, but would I list it just once or twice with a -59 modifier. Someone had mentioned to look at 27675, but not sure on that one either.
Thanks in advance for your input!