Wiki Need help for a dx code

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j-fowler57

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Need some help on a dx code.

Dr. states on OR note pre and post operative dx: displaced/fractured osteotomy. Took pt to surgery and performed an open reduction and internal fixation of fractured osteotomy.

No problem coding the surgery but am stumped on the dx. for it. :confused:

Below is all he wrote for hx:

HISTORY OF PRESENT ILLNESS: This patient is a 56-year-old female who had left forefoot reconstructive surgery on 08/17/12 with a normal operative period. The patient was seen on post operative day 3, 08/20/12, at which time patient was having no acute pain but in her post operative views noted that she had plantarly displaced her osteotomy. After patient was given the ramifications and the risks and benefits we have decided to return to the OR to revise the capital fragment and regain the dorsal plantar relationship of the osteotomy. The patient understands the benefits as well as complications and increased risks including delayed healing, non-union, avascular necrosis, infection, RSD, DVT, disability, and death.

Thanks and Happy Friday:)
 
A few questions first.... Osteotomy on which bone(s)? ORIF of which bone(s)? What was the cause of the fracture? Pathologic?
 
This is the op report. Am I missing something for a dx?
THANKS!!


PREOPERATIVE DIAGNOSIS: Displaced / fractured osteotomy – left foot.

POST OPERATIVE DIAGNOSIS: Displaced / fractured osteotomy – left foot.

PROCEDURE: Open reduction and internal fixation of fractured osteotomy.

DESCRIPTION OF OPERATION: The patient was taken to the surgical suite and placed on the table in supine position. Anesthesia was achieved via IV sedation with local infiltration of a total of 12 ml of 50/50 mixture of 2% Xylocaine plain and 0.5% Marcaine plain. Once anesthesia was achieved the left foot was prepped and draped in the usual sterile manner. Attention was directed to the left foot where the skin sutures were removed. Blunt dissection to the capsular incision, which had excision of the deep sutures, and continued blunt dissection to deliver the head of the metatarsal proximal phalanx which was noted to be displaced plantarly and distally. The OrthoSorb absorbable fixation was then identified in the fracture site and excised. The hematoma was then curettaged and evacuated and flushed. The osteotomy was then reduced in an effort to decrease delayed non-union the dorsal aspect of the metatarsal osteotomy on the long bone itself was then placed in a neutral position. The capital fragment was then reapplied and fixated with 3 OrthoSorb absorbable fixation in cross K wire technique. The surgical site was then copiously flushed with normal saline. The capsular structures were reapproximated and sutured in a continuous fashion of 3-0 Vicryl. The subcutaneous layer was reapproximated and sutured in a continuous fashion of 4-0 Vicryl. The skin was closed with horizontal mattress sutures of 4-0 Silk. Dressings included Owen Silk, Betadine soaked gauze, 4 x 4, 3” Kerlix, and Coban applied in a moderately compressive manner. Hemostasis during the procedure was achieved via a pneumatic ankle tourniquet at 250 mmHg for 66 minutes. The patient tolerated the surgical procedure well and left the OR alert and awake having stable signs and vascular supply intact to all pedal digits. There were no immediate post operative complications and the patient was prepared for outpatient discharge.
 
Friend, I focused on the OR Report entry "...decrease delayed non-union the dorsal aspect of the metatarsal osteotomy...," but did not find anything for non-union. The best I could find is 998.89 or 998.9. Does not state if problem resulted from failure of some kind....Maybe someone else can take if from here. Hope this helps. :)
 
Thanks! I kept coming up with the 9XXXX code as well. Just didn't know if I was going in the right direction. But I really couldn't see anything else. I'm with you... Any body else have something??

Thanks Hewitt:)
 
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