Looking for coding help on the below op report.
I came up with the following: 35207 (inspection and repair of the radial digital artery) does the body of report substanstiate this?
26160 (excision of giant cell tumor tendon sheath)
64702 (neurolysis of radial digital nerve) is the neurolysis of radial nerve incidental to the tumor removal?
Preoperative Diagnosis: Left ring finger mass.
Postoperative Diagnosis: Left ring finger giant cell tumor of tendon sheath.
Procedure Performed:
1. Excision of left ring finger giant cell tumor of tendon sheath.
2. Neurolysis of the radial digital nerve.
3. Inspection and repair of the radial digital artery.
4. Arthrotomy of the distal interphalangeal joint to extract more of the mass.
Estimated Blood Loss: Minimal.
Anesthesia: Local.
Implants: None.
Preoperative Antibiotics: None initially but we did give her 2 g of Ancef after the case,
secondary to the fact that we had entered the joint.
Complications: None.
Specimen: Giant cell tumor of tendon sheath.
Findings: A giant cell tumor of tendon sheath, which was growing out of the radial aspect of the
volar DIP joint between the tendon and the neurovascular structures.
Indications: This is a 28-year-old female who presented to the office with an annoying mass in
her finger. It looks most like a ganglion cyst, but we discussed it could be anything and she
opted for surgery. As she wanted it removed, I reviewed all potential risks, benefits, alternatives,
and complications of both nonoperative and operative treatments as well as rehabilitation and
projected outcomes for all. I answered all of her questions to her satisfaction. She expressed her
understanding. She chose operative treatment for her mass.
I specifically explained the risks of the procedure included but were not limited to bleeding,
infection, neurovascular injury, postoperative pain, continued pain, non-cosmetic scar, stiffness,
need for revision surgery, tendon or ligament irritation or damage, inability to return to previous
level of work or recreational activity as well as other non-foreseeable complications. In addition,
we discussed possible recurrence. She expressed her understanding and consented for the
procedure.
Side, Site and Consent: On the day of the surgery, I met the patient in the preoperative holding.
We reviewed her demographics. I verified the side, site and marked the correct location by
placing my initials on her left ring finger. I obtained her consent. I gave her the digital block.
Description of Procedure: The patient was then taken to the operative theater and placed
supine on a well-padded OR table. A seatbelt was placed. The limb was prepped with
chlorhexidine and draped sterilely. We performed a time-out.
I tested the patient with a pair of Adson's. She was insensate. We rolled on the finger
tourniquet. I drew out my incision, which was a radially based Brunner incision with 2 legs
crossing the DIP joint. We made this incision with the #15 blade. We dissected down and were
able to gently dissect and reflect the soft tissue and then we identified the mass right away. It
was a brown-colored mass, most consistent with giant cell tumor of tendon sheath. We dissected
further radially and we identified the nerve, which was resting right on top of it. So we needed
to perform neuroplasty in order to free the nerve and protect the nerve. Then, immediately next
to this was the small radial digital artery, which we also needed to protect and remove off the
mass. After this was accomplished, my assistant helped to retract these with a Ragnell and then
from a distal to ulnar direction, I dissected underneath the mass, freeing it from the tendon and,
to my surprise, there was a small stalk that entered the joint. So, we cut out the mass and then
what we needed to do was we retracted the flexor digitorum profundus tendon ulnarly just after
the 5th pulley and we incised the capsule longitudinally. We entered into the joint and we used a
rongeur and a pair of Adson's in order to remove the giant cell tumor of tendon sheath out of the
joint. After we performed this arthrotomy, I then pronated the patient. So, she was no longer
fully supinated, she was about 50%. Then, we were able to peek into the joint and underneath
the capsule. I could not identify any additional giant cell tumor of tendon sheath, so I was
satisfied that we had removed all of the mass. We irrigated copiously. We took another look
and it looked as if there was no additional mass. We then removed the finger tourniquet and the
radial digital artery was intact. Then, we irrigated again and repaired the incision with several
nylon sutures followed by Xeroform and cleaning gauze. The drapes were removed. The arm
was given back to the patient and we did give her antibiotics after; it was just because we came
into the joint as I was not predicting that preoperatively.
I came up with the following: 35207 (inspection and repair of the radial digital artery) does the body of report substanstiate this?
26160 (excision of giant cell tumor tendon sheath)
64702 (neurolysis of radial digital nerve) is the neurolysis of radial nerve incidental to the tumor removal?
Preoperative Diagnosis: Left ring finger mass.
Postoperative Diagnosis: Left ring finger giant cell tumor of tendon sheath.
Procedure Performed:
1. Excision of left ring finger giant cell tumor of tendon sheath.
2. Neurolysis of the radial digital nerve.
3. Inspection and repair of the radial digital artery.
4. Arthrotomy of the distal interphalangeal joint to extract more of the mass.
Estimated Blood Loss: Minimal.
Anesthesia: Local.
Implants: None.
Preoperative Antibiotics: None initially but we did give her 2 g of Ancef after the case,
secondary to the fact that we had entered the joint.
Complications: None.
Specimen: Giant cell tumor of tendon sheath.
Findings: A giant cell tumor of tendon sheath, which was growing out of the radial aspect of the
volar DIP joint between the tendon and the neurovascular structures.
Indications: This is a 28-year-old female who presented to the office with an annoying mass in
her finger. It looks most like a ganglion cyst, but we discussed it could be anything and she
opted for surgery. As she wanted it removed, I reviewed all potential risks, benefits, alternatives,
and complications of both nonoperative and operative treatments as well as rehabilitation and
projected outcomes for all. I answered all of her questions to her satisfaction. She expressed her
understanding. She chose operative treatment for her mass.
I specifically explained the risks of the procedure included but were not limited to bleeding,
infection, neurovascular injury, postoperative pain, continued pain, non-cosmetic scar, stiffness,
need for revision surgery, tendon or ligament irritation or damage, inability to return to previous
level of work or recreational activity as well as other non-foreseeable complications. In addition,
we discussed possible recurrence. She expressed her understanding and consented for the
procedure.
Side, Site and Consent: On the day of the surgery, I met the patient in the preoperative holding.
We reviewed her demographics. I verified the side, site and marked the correct location by
placing my initials on her left ring finger. I obtained her consent. I gave her the digital block.
Description of Procedure: The patient was then taken to the operative theater and placed
supine on a well-padded OR table. A seatbelt was placed. The limb was prepped with
chlorhexidine and draped sterilely. We performed a time-out.
I tested the patient with a pair of Adson's. She was insensate. We rolled on the finger
tourniquet. I drew out my incision, which was a radially based Brunner incision with 2 legs
crossing the DIP joint. We made this incision with the #15 blade. We dissected down and were
able to gently dissect and reflect the soft tissue and then we identified the mass right away. It
was a brown-colored mass, most consistent with giant cell tumor of tendon sheath. We dissected
further radially and we identified the nerve, which was resting right on top of it. So we needed
to perform neuroplasty in order to free the nerve and protect the nerve. Then, immediately next
to this was the small radial digital artery, which we also needed to protect and remove off the
mass. After this was accomplished, my assistant helped to retract these with a Ragnell and then
from a distal to ulnar direction, I dissected underneath the mass, freeing it from the tendon and,
to my surprise, there was a small stalk that entered the joint. So, we cut out the mass and then
what we needed to do was we retracted the flexor digitorum profundus tendon ulnarly just after
the 5th pulley and we incised the capsule longitudinally. We entered into the joint and we used a
rongeur and a pair of Adson's in order to remove the giant cell tumor of tendon sheath out of the
joint. After we performed this arthrotomy, I then pronated the patient. So, she was no longer
fully supinated, she was about 50%. Then, we were able to peek into the joint and underneath
the capsule. I could not identify any additional giant cell tumor of tendon sheath, so I was
satisfied that we had removed all of the mass. We irrigated copiously. We took another look
and it looked as if there was no additional mass. We then removed the finger tourniquet and the
radial digital artery was intact. Then, we irrigated again and repaired the incision with several
nylon sutures followed by Xeroform and cleaning gauze. The drapes were removed. The arm
was given back to the patient and we did give her antibiotics after; it was just because we came
into the joint as I was not predicting that preoperatively.