I have coded 28296-Rt
28270-TA
BUT how would I code for a lateral capsulorrhpahy of the 1st metatarsophalangeal joint??????? tia
Still a newbie Podiatry coder
MB,CCS,CPC
Pre-operative Diagnosis:
1. Hallux abducto valgus right foot
2. Joint contracture 1st MPJ left foot
Post-operative Diagnosis:
Same as above
Procedure:
1. Bunionectomy with distal 1st metatarsal osteotomy right foot
2. Medial capsulotomy 1st metatarsophalangeal joint left foot
3. Lateral capsulorrhaphy 1st metatarsophalangeal joint left foot
Findings: consistent with diagnosis
Estimated Blood Loss: Minimal
Drains: wright medical swanson drain
Total IV Fluids: per anesthesia
Specimens: none
Hemostasis:
A well padded tourniquet was placed about the right ankle set at 250 mmHg
Esmarck ankle tourniquet left ankle
Injectables:
30 mL of 0.5% marcaine plain and 1% plain lidocaine was infiltrated proximal to the incision site.
Implants: (2) 2.0 x 14mm cortical synthes screws
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Attending Attestation: I performed the procedure.
Surgeon: , DPM
Assistants: none
Anesthesia: General LMA anesthesia
Procedure Details
The patient was seen in the Holding Room. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The risks and potential complications of their problem and purposed treatment include but are not limited to infection, nerve injury, vascular injury, nonunion of the syndesmosis, persistent pain, potential skin necrosis, deep vein thrombosis, possible pulmonary embolus, complications of the anesthetics and failure of the implant. The patient concurred with the proposed plan, giving informed consent. The site of surgery properly noted/marked. The patient was identified as xxxxx and the procedure verified. A Time Out was held and the above information confirmed.
The patient was brought to the operating room, placed in the supine position on the operative table.
After adequate induction of anesthesia, the tourniquet was placed, the patient?s right lower extremity was prepped and draped in the usual sterile fashion.
The right lower leg was elevated and the exsanguinated with an esmarch bandage.
Procedure #1 - Bunionectomy with distal 1st metatarsal osteotomy
-Attention is now directed to the dorsal medial aspect of the patient?s right, where a linear longitudinal incision of approximately 8cm was made just medial to the EHL tendon.
- This incision was carried deep utilizing a combination of blunt and sharp dissection, carefully retracting aside all major NV structures and tendons, taking care to clamp and bovie all bleeders when necessary.
- At the level of the 1st MPJ capsule, a linear longitudinal capsulotomy in line with the skin incision was performed in order to gain access to the interior surface of the 1st MPJ.
- Sharp dissection was then carried down to the 1st metatarsal head to free all ST attachments from the medial, dorsomedial and dorsolateral aspects of the head of the 1st metatarsal.
- A retractor was used in combination with PF of the hallux in order to introduce the head of the 1st metatarsal in to the operative site.
- Inspection of the head of the 1st metatarsal then showed a dorsomedial prominent exostosis that was noted and resected utilizing a oscillating saw and removed from the operative site.
- Any osseous ledges or spicules were then smoothed with (rasp, burr, rongeur).
- Attention was then directed to the 1st intermetatarsal space where deep dissection was carried out utilizing a combination of blunt and sharp dissection, carefully retracting aside all major NV structures and tendons, taking care to clamp and bovie all bleeders when necessary.
- Attention was then directed to the tendon of the ADH muscle, which was freed from its insertion into the lateral aspect of the fibular sesamoid and the base of the proximal phalanx.
- This was dissected to the most proximal extent within the intermetatarsal space.
- An approximate 1.5cm section of the ADH tendon was resected and removed from the operative site.
- Attention was then directed to the fibular sesamoid which was freed from its dorsal, distal, proximal and plantar attachements and allowed to retract back under the 1st metatarsal head.
- Plantar loading of the 1st MPJ then showed some correction of the 1st IMA and HAA.
- It was decided that more correction was needed, so attention was directed to the medial aspect of the head of the 1st metatarsal where an (Austin / Kalish / Youngswick) osteotomy with a slightly longer dorsal arm was performed with the apex distally and the arms extending proximally into the metaphyseal bone.
- At this time, distal distraction with lateral transposition was applied to the capital fragment, moving the capital fragment 1/3 the width of the 1st metatarsal laterally and the corrected position was then obtained.
- The osteotomy was then temporarily fixated with a 0.045 K-wire for stabilization of the capital fragment.
- Using principles of AO fixation, the osteotomy was then fixated with 2 screws.
- The screws measured 2 separate 2.0 x 14mm.
- The screws were oriented half way between perpendicular to the long axis of the shaft of the 1st metatarsal and the perpendicular to the osteotomy site.
- The medial overhanging shelf of bone was the resected utilizing an oscillating saw and removed from the operative site.
- The remaining osseous surface was then smoothed with a reciprocating rasp.
- Plantar loading of the 1st MPJ then showed good correction of the 1st IMA and HAA.
The wound was flushed with copious amounts of normal physiologic sterile saline and inspected for any soft tissue or osseous debris, none of which was found.
Intra-operative fluoroscopy was prepped and draped and brought into the operative site, for evaluation of the correction.
The correction was found to be adequate.
The capsule/periosteum was reapproximated with 4-0 vircyl suture.
The subcutaneous tissue was reapproximated with 4-0 monocryl suture.
The skin edges were reapproximated with 4-0 Prolene suture.
Wright Medical Swanson drain applied to the right foot.
Postoperative bandage was applied to the Right foot incision site consisting of Adaptec 4 X 4 gauze, Kling gauze, Kerlix gauze, and Coban self-adhering tape, postoperative shoe.
The pneumatic ankle tourniquet was released with immediate reactive hyperemia noted to the digits of the patient?s right foot.
Procedure #2 & #3 Medial capsulotomy and lateral capsulorrhaphy left 1st MPJ
The left lower leg was elevated and the exsanguinated with an esmarch bandage.
Esmarch bandage was then released distally but maintained proximally above the malleoli for hemostasis throughout the procedure
Attention was directed to the dorsomedial aspect of the left 1st metatarsophalangeal joint where a 1 cm linear longitudinal incision was made. Dissection was carried out to the level of the 1st metatarsal phalangeal joint capsule medially in which a 15 blade was utilized to perform a medial capsulotomy. Reduction in the slight adduction contracture of the left hallux was relaxed. The wound was flushed with copious amounts of normal physiologic sterile saline and inspected for any remaining soft tissue or osseous debris, none which was found. At this time a 2nd small 0.5 cm linear longitudinal incision was made along the dorsolateral aspect of the left 1st metatarsophalangeal joint. Dissection was carried down to the lateral aspect of the left 1st metatarsophalangeal joint capsule. At this time a capsulorrhaphy was performed using 2-0 Vicryl suture on a UR 6 needle. Further reduction of the contracture was noted. The hallux was noted to be in a rectus / slightly abducted position.
Intraoperative fluoroscopy was brought in to the office for evaluation of the correction. The correction was found to be adequate.
The subcutaneous tissue was reapproximated with 4-0 Monocryl suture. The skin was reapproximated with 4-0 Prolene suture.
Postoperative bandage was applied to the Right foot incision site consisting of Adaptec 4 X 4 gauze, Kling gauze, Kerlix gauze, and Coban self-adhering tape, postoperative shoe.
The patient tolerated the anesthesia and procedure well and left the operating room with vital signs stable and vascular status intact.
The patient was transported to the recovery room for continued monitoring until the criteria for discharge summary had been met.
28270-TA
BUT how would I code for a lateral capsulorrhpahy of the 1st metatarsophalangeal joint??????? tia
Still a newbie Podiatry coder
MB,CCS,CPC
Pre-operative Diagnosis:
1. Hallux abducto valgus right foot
2. Joint contracture 1st MPJ left foot
Post-operative Diagnosis:
Same as above
Procedure:
1. Bunionectomy with distal 1st metatarsal osteotomy right foot
2. Medial capsulotomy 1st metatarsophalangeal joint left foot
3. Lateral capsulorrhaphy 1st metatarsophalangeal joint left foot
Findings: consistent with diagnosis
Estimated Blood Loss: Minimal
Drains: wright medical swanson drain
Total IV Fluids: per anesthesia
Specimens: none
Hemostasis:
A well padded tourniquet was placed about the right ankle set at 250 mmHg
Esmarck ankle tourniquet left ankle
Injectables:
30 mL of 0.5% marcaine plain and 1% plain lidocaine was infiltrated proximal to the incision site.
Implants: (2) 2.0 x 14mm cortical synthes screws
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Attending Attestation: I performed the procedure.
Surgeon: , DPM
Assistants: none
Anesthesia: General LMA anesthesia
Procedure Details
The patient was seen in the Holding Room. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The risks and potential complications of their problem and purposed treatment include but are not limited to infection, nerve injury, vascular injury, nonunion of the syndesmosis, persistent pain, potential skin necrosis, deep vein thrombosis, possible pulmonary embolus, complications of the anesthetics and failure of the implant. The patient concurred with the proposed plan, giving informed consent. The site of surgery properly noted/marked. The patient was identified as xxxxx and the procedure verified. A Time Out was held and the above information confirmed.
The patient was brought to the operating room, placed in the supine position on the operative table.
After adequate induction of anesthesia, the tourniquet was placed, the patient?s right lower extremity was prepped and draped in the usual sterile fashion.
The right lower leg was elevated and the exsanguinated with an esmarch bandage.
Procedure #1 - Bunionectomy with distal 1st metatarsal osteotomy
-Attention is now directed to the dorsal medial aspect of the patient?s right, where a linear longitudinal incision of approximately 8cm was made just medial to the EHL tendon.
- This incision was carried deep utilizing a combination of blunt and sharp dissection, carefully retracting aside all major NV structures and tendons, taking care to clamp and bovie all bleeders when necessary.
- At the level of the 1st MPJ capsule, a linear longitudinal capsulotomy in line with the skin incision was performed in order to gain access to the interior surface of the 1st MPJ.
- Sharp dissection was then carried down to the 1st metatarsal head to free all ST attachments from the medial, dorsomedial and dorsolateral aspects of the head of the 1st metatarsal.
- A retractor was used in combination with PF of the hallux in order to introduce the head of the 1st metatarsal in to the operative site.
- Inspection of the head of the 1st metatarsal then showed a dorsomedial prominent exostosis that was noted and resected utilizing a oscillating saw and removed from the operative site.
- Any osseous ledges or spicules were then smoothed with (rasp, burr, rongeur).
- Attention was then directed to the 1st intermetatarsal space where deep dissection was carried out utilizing a combination of blunt and sharp dissection, carefully retracting aside all major NV structures and tendons, taking care to clamp and bovie all bleeders when necessary.
- Attention was then directed to the tendon of the ADH muscle, which was freed from its insertion into the lateral aspect of the fibular sesamoid and the base of the proximal phalanx.
- This was dissected to the most proximal extent within the intermetatarsal space.
- An approximate 1.5cm section of the ADH tendon was resected and removed from the operative site.
- Attention was then directed to the fibular sesamoid which was freed from its dorsal, distal, proximal and plantar attachements and allowed to retract back under the 1st metatarsal head.
- Plantar loading of the 1st MPJ then showed some correction of the 1st IMA and HAA.
- It was decided that more correction was needed, so attention was directed to the medial aspect of the head of the 1st metatarsal where an (Austin / Kalish / Youngswick) osteotomy with a slightly longer dorsal arm was performed with the apex distally and the arms extending proximally into the metaphyseal bone.
- At this time, distal distraction with lateral transposition was applied to the capital fragment, moving the capital fragment 1/3 the width of the 1st metatarsal laterally and the corrected position was then obtained.
- The osteotomy was then temporarily fixated with a 0.045 K-wire for stabilization of the capital fragment.
- Using principles of AO fixation, the osteotomy was then fixated with 2 screws.
- The screws measured 2 separate 2.0 x 14mm.
- The screws were oriented half way between perpendicular to the long axis of the shaft of the 1st metatarsal and the perpendicular to the osteotomy site.
- The medial overhanging shelf of bone was the resected utilizing an oscillating saw and removed from the operative site.
- The remaining osseous surface was then smoothed with a reciprocating rasp.
- Plantar loading of the 1st MPJ then showed good correction of the 1st IMA and HAA.
The wound was flushed with copious amounts of normal physiologic sterile saline and inspected for any soft tissue or osseous debris, none of which was found.
Intra-operative fluoroscopy was prepped and draped and brought into the operative site, for evaluation of the correction.
The correction was found to be adequate.
The capsule/periosteum was reapproximated with 4-0 vircyl suture.
The subcutaneous tissue was reapproximated with 4-0 monocryl suture.
The skin edges were reapproximated with 4-0 Prolene suture.
Wright Medical Swanson drain applied to the right foot.
Postoperative bandage was applied to the Right foot incision site consisting of Adaptec 4 X 4 gauze, Kling gauze, Kerlix gauze, and Coban self-adhering tape, postoperative shoe.
The pneumatic ankle tourniquet was released with immediate reactive hyperemia noted to the digits of the patient?s right foot.
Procedure #2 & #3 Medial capsulotomy and lateral capsulorrhaphy left 1st MPJ
The left lower leg was elevated and the exsanguinated with an esmarch bandage.
Esmarch bandage was then released distally but maintained proximally above the malleoli for hemostasis throughout the procedure
Attention was directed to the dorsomedial aspect of the left 1st metatarsophalangeal joint where a 1 cm linear longitudinal incision was made. Dissection was carried out to the level of the 1st metatarsal phalangeal joint capsule medially in which a 15 blade was utilized to perform a medial capsulotomy. Reduction in the slight adduction contracture of the left hallux was relaxed. The wound was flushed with copious amounts of normal physiologic sterile saline and inspected for any remaining soft tissue or osseous debris, none which was found. At this time a 2nd small 0.5 cm linear longitudinal incision was made along the dorsolateral aspect of the left 1st metatarsophalangeal joint. Dissection was carried down to the lateral aspect of the left 1st metatarsophalangeal joint capsule. At this time a capsulorrhaphy was performed using 2-0 Vicryl suture on a UR 6 needle. Further reduction of the contracture was noted. The hallux was noted to be in a rectus / slightly abducted position.
Intraoperative fluoroscopy was brought in to the office for evaluation of the correction. The correction was found to be adequate.
The subcutaneous tissue was reapproximated with 4-0 Monocryl suture. The skin was reapproximated with 4-0 Prolene suture.
Postoperative bandage was applied to the Right foot incision site consisting of Adaptec 4 X 4 gauze, Kling gauze, Kerlix gauze, and Coban self-adhering tape, postoperative shoe.
The patient tolerated the anesthesia and procedure well and left the operating room with vital signs stable and vascular status intact.
The patient was transported to the recovery room for continued monitoring until the criteria for discharge summary had been met.
