peporter
Guru
Good morning coders, I have a hand surgery that the surgeon coded but I don't feel the documentation supports what he wants to code and I'm not sure what procedures could be bundled. I have the op note and his codes. Am I making this harder than it should be? I need your advice. Thanks, Paula
Left hand dog bite with deep infection.
POSTOP DIAGNOSIS
Left hand dog bite with deep infection with left hand penetrating wound
of dog bite in the first and second web space with deep palmar space
infection, with flexor tenosynovitis of the fingers and deep infection
in the carpal tunnel in Guyon's canal.
PROCEDURE
1. Left first and second web space exploration of separate penetrating
wounds, left thumb, index, long, ring and small finger A1 pulley
release, left hand deep palmar multiple bursa infections with irrigation
and debridement.
2. Left flexor tendon sheath of the thumb, index, long, ring and small
finger irrigation and debridement.
3. Left Guyon's canal and carpal tunnel release.
4. Left tenosynovectomy of the flexor digitorum sublimis of the small,
ring, long and index finger.
ANESTHESIA
General.
DESCRIPTION OF PROCEDURE
The patient was identified in preop holding, both verbally and by her
identification tag, transferred to the operative suite and placed on the
operating table in supine position. Anesthesia saw the patient, gave
her general anesthetics, secured her airway. The patient's left hand
was all very firm and tense, swollen. Her fingers were in a flexed
position. She, at this point, had a puncture wound which was closed
over the dorsal first and second web space, these were incised.
Exploration of the penetrating wounds was performed and explored. She
had some thickened serous fluid from these. There was no abscess or
pus. No foreign body. The patient then had a carpal tunnel incision
made over the ulnar border of the carpal tunnel. Dissection was carried
down and Guyon's canal was identified and released. She had thickened
serous fluid in Guyon's canal. Ulnar neurovascular bundle was protected
and the transverse carpal tunnel was released off the hook of the
hamate. There was purulent pus and thickened synovial fluid in the
carpal tunnel. The flexor tendons had thickened tenosynovium.
Tenosynovectomy was performed. The median nerve was identified and
protected. The patient's deep bursae were irrigated and debrided in the
deep bursal spaces of the hand. The patient had incisions made over the
A1 pulley of the thumb, index, long, ring and small finger and these
fingers then had dissection carried down over the A1 pulley. The
neurovascular structures were protected. The A1 pulley was released.
Each of the flexor tendon sheaths had thickened purulent material with
even some thickened pus in the long and index finger. The patient
underwent irrigation and lavage with 1 liter of normal saline and bulb
syringe lavage of the hand followed by 2 liters of normal saline. After
thorough irrigation and debridement, the tissue seemed appropriate. The
pus was gone. The tenosynovium, which was pathologic, was debrided.
The patient's wounds were closed with 4-0 nylon suture. They were left
loosely approximated and a Silastic drain was placed in each wound. She
had eight Silastic drains placed. A sterile dressing was applied
followed by a volar wrist splint. She was transferred to PACU in stable
condition.
The surgeon coded:
20103 x2
26020 x5
26145 x5
64721
64719
Should the I&D of the bursae be coded with 26030?
Is the 26020 part of 26145?
Is the A1 pulley release billable ? and did he document how many he did?
questions, questions, questions.....am I over thinking this?
Left hand dog bite with deep infection.
POSTOP DIAGNOSIS
Left hand dog bite with deep infection with left hand penetrating wound
of dog bite in the first and second web space with deep palmar space
infection, with flexor tenosynovitis of the fingers and deep infection
in the carpal tunnel in Guyon's canal.
PROCEDURE
1. Left first and second web space exploration of separate penetrating
wounds, left thumb, index, long, ring and small finger A1 pulley
release, left hand deep palmar multiple bursa infections with irrigation
and debridement.
2. Left flexor tendon sheath of the thumb, index, long, ring and small
finger irrigation and debridement.
3. Left Guyon's canal and carpal tunnel release.
4. Left tenosynovectomy of the flexor digitorum sublimis of the small,
ring, long and index finger.
ANESTHESIA
General.
DESCRIPTION OF PROCEDURE
The patient was identified in preop holding, both verbally and by her
identification tag, transferred to the operative suite and placed on the
operating table in supine position. Anesthesia saw the patient, gave
her general anesthetics, secured her airway. The patient's left hand
was all very firm and tense, swollen. Her fingers were in a flexed
position. She, at this point, had a puncture wound which was closed
over the dorsal first and second web space, these were incised.
Exploration of the penetrating wounds was performed and explored. She
had some thickened serous fluid from these. There was no abscess or
pus. No foreign body. The patient then had a carpal tunnel incision
made over the ulnar border of the carpal tunnel. Dissection was carried
down and Guyon's canal was identified and released. She had thickened
serous fluid in Guyon's canal. Ulnar neurovascular bundle was protected
and the transverse carpal tunnel was released off the hook of the
hamate. There was purulent pus and thickened synovial fluid in the
carpal tunnel. The flexor tendons had thickened tenosynovium.
Tenosynovectomy was performed. The median nerve was identified and
protected. The patient's deep bursae were irrigated and debrided in the
deep bursal spaces of the hand. The patient had incisions made over the
A1 pulley of the thumb, index, long, ring and small finger and these
fingers then had dissection carried down over the A1 pulley. The
neurovascular structures were protected. The A1 pulley was released.
Each of the flexor tendon sheaths had thickened purulent material with
even some thickened pus in the long and index finger. The patient
underwent irrigation and lavage with 1 liter of normal saline and bulb
syringe lavage of the hand followed by 2 liters of normal saline. After
thorough irrigation and debridement, the tissue seemed appropriate. The
pus was gone. The tenosynovium, which was pathologic, was debrided.
The patient's wounds were closed with 4-0 nylon suture. They were left
loosely approximated and a Silastic drain was placed in each wound. She
had eight Silastic drains placed. A sterile dressing was applied
followed by a volar wrist splint. She was transferred to PACU in stable
condition.
The surgeon coded:
20103 x2
26020 x5
26145 x5
64721
64719
Should the I&D of the bursae be coded with 26030?
Is the 26020 part of 26145?
Is the A1 pulley release billable ? and did he document how many he did?
questions, questions, questions.....am I over thinking this?