Need help with coding procedure! Thanks in advance!!


Little Elm , TX
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Hello everyone!

I am needing some help coding the following OP report: any help would be greatly appreciated!!!:)

DESCRIPTION OF PROCEDURE: Under mild IV sedation, the patient was brought back into the operating room and placed on the operating table in the supine position. A well-padded ankle tourniquet was applied to the right ankle. Anesthesia was administered by Anesthesia Services. Local anesthetic was administered as stated above. Following a time-out, the lower extremity was scrubbed, prepped, and draped in the normal sterile fashion. The extremity was exsanguinated using an Esmarch bandage and tourniquet was inflated. Attention was then directed to the medial aspect of the right foot where a longitudinal incision was made medially at the level of the medial cuneiform. This was then sharply opened and debrided, and the dissection was carried down to bone using a mixture of sharp and blunt dissection.

The capsule was delicately reflected. All neurovascular structures were identified and care was taken to avoid these. Medial exostosis and plantar exostosis were then debrided and removed using an osteotome and mallet. These were then passed off the operative field. The area was immediately felt for areas of prominence. All areas were then removed using a hand rasp. The entirety of the operative site was then rinsed using copious amounts of sterile saline. Following this, all capsular and deep tissues were reapproximated using 3-0 Vicryl. Subcutaneous tissues were then closed using same 3-0 Vicryl, and the skin was closed using 4-0 nylon. The incision was then dressed using Adaptic, 4x4’s, Kling, and an Ace bandage. Tourniquet was deflated and a prompt hyperemic response was noted to all digits distally. The patient tolerated the procedure well and was transferred to PACU with vital signs stable and vascular status intact. was present and scrubbed for the entirety of the case and directed care.