Hi All,
I'm stuck. One of our docs is adamant that his operative report documents something that none of our coders can find. His heading states "DeVries arthroplasty, right second, third, and fourth proximal interphalangeal joints" (bolded below) We could not find it to be documented in the operative report, so our office queried him and he responded by circling this section of the OP report "A wedge of skin and extensor tendon were removed from the second PIP joint. This joint was fixated with an OrthoSorb pin. The same was done for the third PIP and fourth PIP as well, but a pin was not necessary" (bolded below)
I don't read that as an arthroplasty, but he is adamant that it is. Can anyone help me explain WHY his documentation is insufficient? Full Op Report copied below
POSTOPERATIVE DIAGNOSES:
1. Metatarsalgia, right second and third.
2. Hallux rigidus, right.
3. Claw toe, right second, third, and fourth.
PROCEDURES PERFORMED:
1. Metatarsal neck osteotomy, right second and third.
2. Varus deformity correction, soft tissue, right second.
3. Cheilectomy, right hallux metatarsophalangeal.
4. DeVries arthroplasty, right second, third, and fourth proximal interphalangeal joints.
5. Extensor tenotomy and dorsal capsulotomy, right third metarsophalangeal joint.
SURGICAL FINDINGS: There was end-stage degeneration of the dorsal two-thirds of the hallux metarsophalangeal joint as well as the dorsal two-thirds of the second metarsophalangeal joint with spurring.
Because of the significant degenerative changes, the plantar plate was fairly stable, it was elected not to do a plantar plate repair, but just balance the soft tissues around the second MTP.
DESCRIPTION OF PROCEDURE: After adequate anesthesia, the right leg was prepped and draped in the usual fashion. An ankle block was done with 20 mL of 0.5% Marcaine plain. The thigh tourniquet was elevated after exsanguination to 280 mmHg for about 65 minutes. A direct medial approach was made over the first MTP. Capsulotomy was performed. A cheilectomy was carried out of the MTP.
Some drilling was done of the dorsal first metatarsal bone with a 0.062 K-wire. Good motion was obtained.
An incision was made between the second and third metatarsal heads. Extensor tenotomy and dorsal capsulotomy were carried out for both. Metatarsal neck osteotomy was done of the second and then third and both were shortened appropriately and fixated with a breakaway Arthrex screw. Good fixation was obtained. The dorsal rim was shaved down. The joints were debrided. Some of the varus deformity was corrected and lateral reefing was done with 2-0 Vicryl of the second MTP.
A wedge of skin and extensor tendon were removed from the second PIP joint. This joint was fixated with an OrthoSorb pin. The same was done for the third PIP and fourth PIP as well, but a pin was not necessary. The wounds were well irrigated with antibiotic solution and closed in layers with 2-0 Vicryl, 3-0 Vicryl, and 4-0 nylon. Toe strapping was done in the usual fashion. When the tourniquet was released, toes were noted to be pink. There were no complications.
I'm stuck. One of our docs is adamant that his operative report documents something that none of our coders can find. His heading states "DeVries arthroplasty, right second, third, and fourth proximal interphalangeal joints" (bolded below) We could not find it to be documented in the operative report, so our office queried him and he responded by circling this section of the OP report "A wedge of skin and extensor tendon were removed from the second PIP joint. This joint was fixated with an OrthoSorb pin. The same was done for the third PIP and fourth PIP as well, but a pin was not necessary" (bolded below)
I don't read that as an arthroplasty, but he is adamant that it is. Can anyone help me explain WHY his documentation is insufficient? Full Op Report copied below
POSTOPERATIVE DIAGNOSES:
1. Metatarsalgia, right second and third.
2. Hallux rigidus, right.
3. Claw toe, right second, third, and fourth.
PROCEDURES PERFORMED:
1. Metatarsal neck osteotomy, right second and third.
2. Varus deformity correction, soft tissue, right second.
3. Cheilectomy, right hallux metatarsophalangeal.
4. DeVries arthroplasty, right second, third, and fourth proximal interphalangeal joints.
5. Extensor tenotomy and dorsal capsulotomy, right third metarsophalangeal joint.
SURGICAL FINDINGS: There was end-stage degeneration of the dorsal two-thirds of the hallux metarsophalangeal joint as well as the dorsal two-thirds of the second metarsophalangeal joint with spurring.
Because of the significant degenerative changes, the plantar plate was fairly stable, it was elected not to do a plantar plate repair, but just balance the soft tissues around the second MTP.
DESCRIPTION OF PROCEDURE: After adequate anesthesia, the right leg was prepped and draped in the usual fashion. An ankle block was done with 20 mL of 0.5% Marcaine plain. The thigh tourniquet was elevated after exsanguination to 280 mmHg for about 65 minutes. A direct medial approach was made over the first MTP. Capsulotomy was performed. A cheilectomy was carried out of the MTP.
Some drilling was done of the dorsal first metatarsal bone with a 0.062 K-wire. Good motion was obtained.
An incision was made between the second and third metatarsal heads. Extensor tenotomy and dorsal capsulotomy were carried out for both. Metatarsal neck osteotomy was done of the second and then third and both were shortened appropriately and fixated with a breakaway Arthrex screw. Good fixation was obtained. The dorsal rim was shaved down. The joints were debrided. Some of the varus deformity was corrected and lateral reefing was done with 2-0 Vicryl of the second MTP.
A wedge of skin and extensor tendon were removed from the second PIP joint. This joint was fixated with an OrthoSorb pin. The same was done for the third PIP and fourth PIP as well, but a pin was not necessary. The wounds were well irrigated with antibiotic solution and closed in layers with 2-0 Vicryl, 3-0 Vicryl, and 4-0 nylon. Toe strapping was done in the usual fashion. When the tourniquet was released, toes were noted to be pink. There were no complications.