Can anyone please help me on how to code this surgical procedure?
Preoperative Diagnosis: Open Fracture, Right Thumb, with soft tissue crushing injury requiring bone and soft tissue reconstruction, dominant right thumb.
The patient was prepped and draped following standard fashion. Open reduction and 0.035 K-wire fixation to stabilize the skeleton in a 360-degree orientation appropriately was done. Pulse lavage irrigation was performed. Debridement of the thumb crush injury wound. A void at the distal aspect of the volar thumb was noted. The injury was primarily on the radial aspect which was extended and examined following the standard Moberg tyep of sensate fasciocutaneous advancement. Since it is his volar pad and it is his dominant right thumb, the IP was flexed approximately 30 degrees and a K-wire was placed in the dorsal aspect going through the IP to hold in a stabilized position. Debridement and repair of a 0.45 cm independent ulnar laceration wa performed. Repair of 1 cm dorsal simple laceration was performed. Reconstruction of a partial injury of the radial collateral ligament with permanent suture was performed. Distal vascularity was assured to be intact. The distal aspect of the area was covered over vascularized sensate tissue with full thickness skin graft to minimize secondary scar contracture. Satisfactory reconstruction was accomplished. Antibiotic ointment and Xeroform were applied to the top of the repair. A thumb spica splint was applied at the conclusion of the procedure to maintain stability of the skeletal fixation.
Preoperative Diagnosis: Open Fracture, Right Thumb, with soft tissue crushing injury requiring bone and soft tissue reconstruction, dominant right thumb.
The patient was prepped and draped following standard fashion. Open reduction and 0.035 K-wire fixation to stabilize the skeleton in a 360-degree orientation appropriately was done. Pulse lavage irrigation was performed. Debridement of the thumb crush injury wound. A void at the distal aspect of the volar thumb was noted. The injury was primarily on the radial aspect which was extended and examined following the standard Moberg tyep of sensate fasciocutaneous advancement. Since it is his volar pad and it is his dominant right thumb, the IP was flexed approximately 30 degrees and a K-wire was placed in the dorsal aspect going through the IP to hold in a stabilized position. Debridement and repair of a 0.45 cm independent ulnar laceration wa performed. Repair of 1 cm dorsal simple laceration was performed. Reconstruction of a partial injury of the radial collateral ligament with permanent suture was performed. Distal vascularity was assured to be intact. The distal aspect of the area was covered over vascularized sensate tissue with full thickness skin graft to minimize secondary scar contracture. Satisfactory reconstruction was accomplished. Antibiotic ointment and Xeroform were applied to the top of the repair. A thumb spica splint was applied at the conclusion of the procedure to maintain stability of the skeletal fixation.