cclarson
Guru
Hello Everyone! I'm not sure how I'm suppose to code this particular part of a patient's procedure. Part of me thinks that this is 25020-25023, but a second opinion is always welcome. Thank you!
Here is the Report:
POSTOPERATIVE DIAGNOSES:
1. Right carpal tunnel syndrome.
2. Intersection syndrome.
3. Index and long trigger fingers.
PROCEDURES PERFORMED:
1. Right carpal tunnel release.
2. Intersection syndrome compartment release.
3. Index and long trigger finger releases.
Indications:
The patient presents with symptomatic carpal tunnel syndrome, trigger fingers, and intersection syndrome that have failed nonoperative treatment. She also had some other complaints of pain around her thumb and mildly at the first extensor compartment. She elects to proceed with surgery as scheduled. We discussed that she may continue to have some pain that may require additional procedures in the future.
DESCRIPTION OF PROCEDURE:
Procedure #1: Right carpal tunnel release:
The patient was identified and marked in the preoperative holding area. They were then brought to the operating room and placed supine with the right hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. Time-out was performed and preoperative antibiotics were given.
An incision was made in the right palm in line with the fourth ray. We dissected down through the subcutaneous tissues to the transverse carpal ligament. This was divided longitudinally. The distal extent of the ligament was released with scissors to the palmar fat. We then turned our attention proximally and the antebrachial fascia was released under direct visualization. The median nerve appeared compressed. The wound was irrigated and then was closed with interrupted nylon sutures. A bulky soft sterile dressing was applied.
Procedure #2: Right index and long trigger finger releases:
The patient was brought to the operating room and placed supine with the right hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. Time-out was performed and preoperative antibiotics were given.
A longitudinal incision was made over the right index and long trigger fingers. We dissected down to the flexor sheath and the A1 pulley was identified. This was then released longitudinally. The tendons were retracted out of the wound with a Ragnell retractor to free any adhesions. The wound was then irrigated and was closed with 4-0 nylon. A soft sterile dressing was applied.
Procedure #3: Intersection syndrome compartment release:
An incision was then made over the dorsum of the forearm. We dissected down through the subcutaneous tissues to the first extensor musculature. The fascia was opened, and the muscles were then mobilized. We then released the fascia over the second extensor tendons. There was appeared to be some synovitis. At this point, the wrist was taken through range of motion and was stable. The wounds were then irrigated and were closed with interrupted nylon and Monocryl. A dorsal splint was applied. The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.
Here is the Report:
POSTOPERATIVE DIAGNOSES:
1. Right carpal tunnel syndrome.
2. Intersection syndrome.
3. Index and long trigger fingers.
PROCEDURES PERFORMED:
1. Right carpal tunnel release.
2. Intersection syndrome compartment release.
3. Index and long trigger finger releases.
Indications:
The patient presents with symptomatic carpal tunnel syndrome, trigger fingers, and intersection syndrome that have failed nonoperative treatment. She also had some other complaints of pain around her thumb and mildly at the first extensor compartment. She elects to proceed with surgery as scheduled. We discussed that she may continue to have some pain that may require additional procedures in the future.
DESCRIPTION OF PROCEDURE:
Procedure #1: Right carpal tunnel release:
The patient was identified and marked in the preoperative holding area. They were then brought to the operating room and placed supine with the right hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. Time-out was performed and preoperative antibiotics were given.
An incision was made in the right palm in line with the fourth ray. We dissected down through the subcutaneous tissues to the transverse carpal ligament. This was divided longitudinally. The distal extent of the ligament was released with scissors to the palmar fat. We then turned our attention proximally and the antebrachial fascia was released under direct visualization. The median nerve appeared compressed. The wound was irrigated and then was closed with interrupted nylon sutures. A bulky soft sterile dressing was applied.
Procedure #2: Right index and long trigger finger releases:
The patient was brought to the operating room and placed supine with the right hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. Time-out was performed and preoperative antibiotics were given.
A longitudinal incision was made over the right index and long trigger fingers. We dissected down to the flexor sheath and the A1 pulley was identified. This was then released longitudinally. The tendons were retracted out of the wound with a Ragnell retractor to free any adhesions. The wound was then irrigated and was closed with 4-0 nylon. A soft sterile dressing was applied.
Procedure #3: Intersection syndrome compartment release:
An incision was then made over the dorsum of the forearm. We dissected down through the subcutaneous tissues to the first extensor musculature. The fascia was opened, and the muscles were then mobilized. We then released the fascia over the second extensor tendons. There was appeared to be some synovitis. At this point, the wrist was taken through range of motion and was stable. The wounds were then irrigated and were closed with interrupted nylon and Monocryl. A dorsal splint was applied. The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.
