annmazzolla
Guest
Our surgeon performed the following procedures. I need help coding the nerve attachment. He thinks code 64787 should be used, but this is an add-on code. I have 26123, & 26525. I need help, can anyone help me with this??
POSTOPERATIVE DIAGNOSES:
1. Right palm and small finger Dupuytren's contracture.
2. Right small finger proximal interphalangeal joint contracture
OPERATIONS PERFORMED:
1. Right small finger and palm fasciectomy removing Dupuytren's tissue.
2. Right small finger PIP joint contracture release.
3. Right palm implantation of nerve into muscle.
4. Right small finger digital artery repair.
COMPLICATION:
Laceration of the digital artery.
During the dissection, the ulnar digital artery was accidentally lacerated and needed to be repaired. There was a branch of the nerve that went into some of the Dupuytren's nodule. This was divided and to a prevent neuroma formation, it was buried into the hypothenar musculature.
NARRATIVE OF PROCEDURE:
After informed consent was obtained and the correct limb identified, the patient was taken to the operating room where general anesthesia was induced. The right upper extremity was prepped and draped in the usual sterile fashion. A sterile marking pen was used to indicate the proposed incision. A surgical timeout was performed confirming the correct patient, limb, and procedure, as well as completion of the prophylactic antibiotic infusion. The limb was exsanguinated with an Esmarch bandage and the tourniquet was inflated.
The skin was incised with a 15 blade along the preplanned marks. Hemostasis was achieved where indicated with bipolar cautery. Dissection continued in blunt and sharp fashion with tenotomy scissors as well as a Beaver blade. The thickened palmar fascial tissue in the palm was first circumferentially dissected and then followed proximally to its attachment to the transverse carpal ligament. It was excised off the transverse carpal ligament and a Kocher was placed on it for traction. It was then followed distally. Great care was taken to identify and protect the ulnar digital nerve. The cord was followed out further where it was also taken off of skin and the intermetacarpal ligaments and the natatory ligaments and Cleland's and Grayson's ligaments. As be dissected free; therefore, it was divided and reflected back. The Dupuytren's cord was followed all the way out to the distal interphalangeal joint before it was removed.
At this point, with the Dupuytren's tissue completely removed, the right small finger still had a 15- to 25-degree flexion contracture and the checkrein ligaments were released. When this was insufficient to fully straighten the finger, the volar plate was released as well.
7-0 Prolene suture was then used to take the small branch that was sacrificed from into the Dupuytren's tissue and it was buried into the hypothenar muscle. The nerve was then followed mentioned above, there was one point where the thick Dupuytren's tissue had a small branch of the digital nerve going right into it and it could not and there was 1 location where the artery was severed. 7-0 Prolene was used under loupe magnification to repair this.
Once the nerve was repaired, the wound was copiously irrigated and hemostasis was again assured. The skin was closed with 5-0 Vicryl and 4-0 nylon. Marcaine 0.25% was instilled for postoperative analgesia. Xeroform, fluffs, Conform, and a volar splint was applied to the small and ring fingers and the palm to keep it in extension. The patient tolerated the procedure well and was awoken, extubated, and taken to recovery in good condition.
POSTOPERATIVE DIAGNOSES:
1. Right palm and small finger Dupuytren's contracture.
2. Right small finger proximal interphalangeal joint contracture
OPERATIONS PERFORMED:
1. Right small finger and palm fasciectomy removing Dupuytren's tissue.
2. Right small finger PIP joint contracture release.
3. Right palm implantation of nerve into muscle.
4. Right small finger digital artery repair.
COMPLICATION:
Laceration of the digital artery.
During the dissection, the ulnar digital artery was accidentally lacerated and needed to be repaired. There was a branch of the nerve that went into some of the Dupuytren's nodule. This was divided and to a prevent neuroma formation, it was buried into the hypothenar musculature.
NARRATIVE OF PROCEDURE:
After informed consent was obtained and the correct limb identified, the patient was taken to the operating room where general anesthesia was induced. The right upper extremity was prepped and draped in the usual sterile fashion. A sterile marking pen was used to indicate the proposed incision. A surgical timeout was performed confirming the correct patient, limb, and procedure, as well as completion of the prophylactic antibiotic infusion. The limb was exsanguinated with an Esmarch bandage and the tourniquet was inflated.
The skin was incised with a 15 blade along the preplanned marks. Hemostasis was achieved where indicated with bipolar cautery. Dissection continued in blunt and sharp fashion with tenotomy scissors as well as a Beaver blade. The thickened palmar fascial tissue in the palm was first circumferentially dissected and then followed proximally to its attachment to the transverse carpal ligament. It was excised off the transverse carpal ligament and a Kocher was placed on it for traction. It was then followed distally. Great care was taken to identify and protect the ulnar digital nerve. The cord was followed out further where it was also taken off of skin and the intermetacarpal ligaments and the natatory ligaments and Cleland's and Grayson's ligaments. As be dissected free; therefore, it was divided and reflected back. The Dupuytren's cord was followed all the way out to the distal interphalangeal joint before it was removed.
At this point, with the Dupuytren's tissue completely removed, the right small finger still had a 15- to 25-degree flexion contracture and the checkrein ligaments were released. When this was insufficient to fully straighten the finger, the volar plate was released as well.
7-0 Prolene suture was then used to take the small branch that was sacrificed from into the Dupuytren's tissue and it was buried into the hypothenar muscle. The nerve was then followed mentioned above, there was one point where the thick Dupuytren's tissue had a small branch of the digital nerve going right into it and it could not and there was 1 location where the artery was severed. 7-0 Prolene was used under loupe magnification to repair this.
Once the nerve was repaired, the wound was copiously irrigated and hemostasis was again assured. The skin was closed with 5-0 Vicryl and 4-0 nylon. Marcaine 0.25% was instilled for postoperative analgesia. Xeroform, fluffs, Conform, and a volar splint was applied to the small and ring fingers and the palm to keep it in extension. The patient tolerated the procedure well and was awoken, extubated, and taken to recovery in good condition.