How would you Code this OP note?
1) 10120 -Foreign body removal
2) 97597 debridement
3) 20130 - Exploration of a penetrating wound
INDICATIONS FOR THE PROCEDURE: The patient is a ??-year-old woman who had an ultrasound report suggestive of a possible 2 mm foreign body. She believes she may have had a puncture wound with wood on the dorsum of that finger and did not completely remove it. She has had some soreness in the area since then and has requested foreign body removal.
DESCRIPTION OF PROCEDURE: The patient was met and marked in the preoperative area. The consent was reviewed. A digital block was performed with 10 mL of 1% lidocaine with epinephrine buffered with sodium bicarbonate. She was brought back to the operating room. The right upper extremity was prepped and draped in the usual sterile fashion with chlorhexidine. A surgical time-out was performed. The patient had a 1 cm erythematous area on the dorsum of her right middle finger PIP joint. This was sharply incised. Blunt dissection was carefully carried down and I explored the entire dorsal surface superficial to the extensor mechanism and find no evidence of foreign body. I removed some normal appearing fat mixed with some fibrotic strands that represented probable scar tissue from a puncture wound. The extensor mechanism was intact. There was no evidence of deeper foreign body requiring a deeper exploration. After adequate exploration, I irrigated the wound with normal saline and reported to the patient that I did not think that there was any remaining foreign body in the finger. The skin was closed with interrupted 4-0 Prolene suture. Adaptic was applied over the sutures followed by a well-padded soft finger dressing. She tolerated the procedure well. There were no complications. Needle and sponge counts were correct. She was brought to the recovery area in stable condition.
1) 10120 -Foreign body removal
2) 97597 debridement
3) 20130 - Exploration of a penetrating wound
INDICATIONS FOR THE PROCEDURE: The patient is a ??-year-old woman who had an ultrasound report suggestive of a possible 2 mm foreign body. She believes she may have had a puncture wound with wood on the dorsum of that finger and did not completely remove it. She has had some soreness in the area since then and has requested foreign body removal.
DESCRIPTION OF PROCEDURE: The patient was met and marked in the preoperative area. The consent was reviewed. A digital block was performed with 10 mL of 1% lidocaine with epinephrine buffered with sodium bicarbonate. She was brought back to the operating room. The right upper extremity was prepped and draped in the usual sterile fashion with chlorhexidine. A surgical time-out was performed. The patient had a 1 cm erythematous area on the dorsum of her right middle finger PIP joint. This was sharply incised. Blunt dissection was carefully carried down and I explored the entire dorsal surface superficial to the extensor mechanism and find no evidence of foreign body. I removed some normal appearing fat mixed with some fibrotic strands that represented probable scar tissue from a puncture wound. The extensor mechanism was intact. There was no evidence of deeper foreign body requiring a deeper exploration. After adequate exploration, I irrigated the wound with normal saline and reported to the patient that I did not think that there was any remaining foreign body in the finger. The skin was closed with interrupted 4-0 Prolene suture. Adaptic was applied over the sutures followed by a well-padded soft finger dressing. She tolerated the procedure well. There were no complications. Needle and sponge counts were correct. She was brought to the recovery area in stable condition.