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help with op note needed!

laurabee

Networker
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43
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i just passed the exam (go me!) but i'm having trouble on this CPT and ICD-9. here's the op report:

PREOP DX: Salter-Harris type 2 fracture of the right lower extremity, distal tibia and fibula with external rotation.

POST OP DX: same.

PROCEDURE: closed reduction and application of sugar tong splint under conscious sedation anesthesia.

PROCEDURE IN DETAIL: the patient underwent a closed reduction. there was an audible and palpable click of reduction as longitudinal traction was placed and internal rotation was placed. good stability was noticed, and the leg appeared symmetric with the opposite side. check radiograph at this point showed good reduction, especially on the lateral view. again the previous displacement was very subtle on the plain films,. but there was definitely clinically symmetric malpositioning of the foot compared with the opposite side. A well-padded, well-molded sugar tong splint with the foot held with anterior traction and internal rotation well. He will be dismissed later this evening.

??
 

mbort

True Blue
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Location
ENGLEWOOD/DENVER
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congratulations Laurabee!!

Unfortunately Laurabee, your doc does not supply enough info about the fracture for this to be coded. Thats probably why you are having a problem with it.

Query the doc. he only states that it was distal tib/fib. Was this bimallelar? Was it distal shaft? was it intraarticular? was it the weight bearing portion? He's definitely going to have to give you something to work with here.
 
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