Hpi states: focal exostosis, dorsal medial cuneiform
Would you code 28104 OR 28304? TIA
Mb,CCS,CPC
PREOPERATIVE DIAGNOSIS(ES):
1. Midfoot exostosis, left
POSTOPERATIVE DIAGNOSIS(ES):
1. Same
OPERATIONS PERFORMED:
1. Midfoot exostectomy, left
ANESTHESIA: LMA - General
FLUIDS:700cc Lactated Ringers
TOURNIQUET
neumatic Ankle Tourniquet at 250mmHg for 18 minutes
ESTIMATED BLOOD LOSS: Less than 5 cc
INJECTABLES: 1:1 mix of Lidocaine 2% & Marcaine 0.5% (without epinephrine), 6 cc
MATERIALS:3-0 Vicryl and 3-0 Nylon
PREPARATION:
1. Patient placed on operative table in supine and secured
2. Time out performed, reconfirming patient identity, consented procedures and surgical sites
3. All members of the surgical team identified themselves.
4. Padded tourniquet placed on left
5. Anesthesia obtained
6. left was prepped in sterile fashion
7. left elevated, manually compressed, tourniquet inflated.
Procedure 1: Dorsal medial midfoot exostectomy
-- 4 cm dorsal linear incision was placed over bony prominence
-- Deepened through subcutaneous tissues, retracting neurovascular structures, periosteum encountered
-- 4 cm linear periosteal incision was competed and reflected exposing exostosis
-- Utilizing sagittal saw and hand rasp, exostosis was removed and smoothed
-- With palpation of area with foot loaded, no palpable bont prominence noted
-- Incision flushed with copious amounts of normal saline
-- Skin incision closed in a layered fashion with above stated suture material
-- Dry sterile dressing placed
Tourniquet was released, noting immediate capillary refill to all digits
Pt was awakened from anesthesia with vital signs stable and neurovascular status intact
was present and scrubbed for the entire duration of this procedure
Would you code 28104 OR 28304? TIA
Mb,CCS,CPC
PREOPERATIVE DIAGNOSIS(ES):
1. Midfoot exostosis, left
POSTOPERATIVE DIAGNOSIS(ES):
1. Same
OPERATIONS PERFORMED:
1. Midfoot exostectomy, left
ANESTHESIA: LMA - General
FLUIDS:700cc Lactated Ringers
TOURNIQUET
neumatic Ankle Tourniquet at 250mmHg for 18 minutesESTIMATED BLOOD LOSS: Less than 5 cc
INJECTABLES: 1:1 mix of Lidocaine 2% & Marcaine 0.5% (without epinephrine), 6 cc
MATERIALS:3-0 Vicryl and 3-0 Nylon
PREPARATION:
1. Patient placed on operative table in supine and secured
2. Time out performed, reconfirming patient identity, consented procedures and surgical sites
3. All members of the surgical team identified themselves.
4. Padded tourniquet placed on left
5. Anesthesia obtained
6. left was prepped in sterile fashion
7. left elevated, manually compressed, tourniquet inflated.
Procedure 1: Dorsal medial midfoot exostectomy
-- 4 cm dorsal linear incision was placed over bony prominence
-- Deepened through subcutaneous tissues, retracting neurovascular structures, periosteum encountered
-- 4 cm linear periosteal incision was competed and reflected exposing exostosis
-- Utilizing sagittal saw and hand rasp, exostosis was removed and smoothed
-- With palpation of area with foot loaded, no palpable bont prominence noted
-- Incision flushed with copious amounts of normal saline
-- Skin incision closed in a layered fashion with above stated suture material
-- Dry sterile dressing placed
Tourniquet was released, noting immediate capillary refill to all digits
Pt was awakened from anesthesia with vital signs stable and neurovascular status intact
was present and scrubbed for the entire duration of this procedure