joanne71178
Guru
Post OP Diagnosis:
Left distal tib-fib fracture with Salter-Harris type II fracture pattern and residual displacement folling closed reduction, casting.
OPERATION PERFORMED:
Left tibia closed reduction, percutaneous screw fixation.
INDICATION:
"This is a 14 year old boy who had a skateboard injury and sustained a displaced left ankle fracture of the distal tibial physis. He underwent a closed reduction. Due to lack of operating room availability he underwent attempted closed reduction In the emergency room which greatly improved his position of the fracture, but he still had mild residual deformity and was brought t outpatient surgery for further reduction and fixation. "
PROCEDURE:
"The patient was brought to the operating room after general anesthesia was induced. The left leg was prepped and draped in sterile orthopedic fashion. Closed reduction was performed with correcting slight lateral displacement of his distal fragment, and correcting mild posterior displacement. AP lateral Mortise views reveal near-anatomic reduction. An incision was made through skin only, gentle spreading through subcutaneous tissue approximately 20 mm lateral to anterior tibialis tendon was performed and blunt dissection was carried out down to bone. K-wire was inserted and over drilled with 2.7 mm cannulated drill bit, and a cannulated 4.0 distally threaded cancellous screw was placed over a washer which nicely further reduced the fracture in the lateral view and there was minimal residual displacement medially. This was felt to be satisfactory after closure of the wound with inverted 2-0 Vicryl subcutaneous sutures. Skin glue and Steri-Strips were applied, followed by a well-padded short leg cast. "
Would the correct codes be:
823.80, E006.0
27826-58 LT ? or an unlisted code?
Thanks in advance.
Left distal tib-fib fracture with Salter-Harris type II fracture pattern and residual displacement folling closed reduction, casting.
OPERATION PERFORMED:
Left tibia closed reduction, percutaneous screw fixation.
INDICATION:
"This is a 14 year old boy who had a skateboard injury and sustained a displaced left ankle fracture of the distal tibial physis. He underwent a closed reduction. Due to lack of operating room availability he underwent attempted closed reduction In the emergency room which greatly improved his position of the fracture, but he still had mild residual deformity and was brought t outpatient surgery for further reduction and fixation. "
PROCEDURE:
"The patient was brought to the operating room after general anesthesia was induced. The left leg was prepped and draped in sterile orthopedic fashion. Closed reduction was performed with correcting slight lateral displacement of his distal fragment, and correcting mild posterior displacement. AP lateral Mortise views reveal near-anatomic reduction. An incision was made through skin only, gentle spreading through subcutaneous tissue approximately 20 mm lateral to anterior tibialis tendon was performed and blunt dissection was carried out down to bone. K-wire was inserted and over drilled with 2.7 mm cannulated drill bit, and a cannulated 4.0 distally threaded cancellous screw was placed over a washer which nicely further reduced the fracture in the lateral view and there was minimal residual displacement medially. This was felt to be satisfactory after closure of the wound with inverted 2-0 Vicryl subcutaneous sutures. Skin glue and Steri-Strips were applied, followed by a well-padded short leg cast. "
Would the correct codes be:
823.80, E006.0
27826-58 LT ? or an unlisted code?
Thanks in advance.