Bella Cullen
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Hello,
Can someone help on this code. I'm new to orthopaedic coding and I'm not sure on this.
Procedure:
Exploration anterior elbow w/lysis of adhesions and exostectomy
Op note says:
A standard lateral approach to the elbow was then utilized through a 4-5 cm curvilinear incision over the lateral aspect. This was just anterior to the lateral epicondyle. This was 4.5 cm anterior to the posterior incision to provide as large a skin bridge as possible. The lateral aspect of the humerus was then identified and care taken to stay on the bone and the soft tissue carefully elevated off the front of the elbow. A small amount of the common extensor tendon had to be divided to visualize the radial head and across the front of the joint. Once this was done, the combination of blunt and sharp dissection retractors were carefully placed across the front of the elbow for visualization. There was some hypertrophic bone and an osteophyte that had formed. These were removed essentially with a rongeur with little bites taken out in pieces. Each time this was done, the range of motion of the elbow was rechecked. Some of the block was actually not from a bony block anteriorly but from soft tissue constriction posteriorly so only about 10-15 degrees may have been gained with this maneuver. Care was taken not to try to do too much and jeopardize the neurovascular structures anteriorly. At that point, the wound was copiously irrigated and closure was initiated. The joint itself actually looked to be in good condition with no evidence of significant arthrosis.
Thanks
Can someone help on this code. I'm new to orthopaedic coding and I'm not sure on this.
Procedure:
Exploration anterior elbow w/lysis of adhesions and exostectomy
Op note says:
A standard lateral approach to the elbow was then utilized through a 4-5 cm curvilinear incision over the lateral aspect. This was just anterior to the lateral epicondyle. This was 4.5 cm anterior to the posterior incision to provide as large a skin bridge as possible. The lateral aspect of the humerus was then identified and care taken to stay on the bone and the soft tissue carefully elevated off the front of the elbow. A small amount of the common extensor tendon had to be divided to visualize the radial head and across the front of the joint. Once this was done, the combination of blunt and sharp dissection retractors were carefully placed across the front of the elbow for visualization. There was some hypertrophic bone and an osteophyte that had formed. These were removed essentially with a rongeur with little bites taken out in pieces. Each time this was done, the range of motion of the elbow was rechecked. Some of the block was actually not from a bony block anteriorly but from soft tissue constriction posteriorly so only about 10-15 degrees may have been gained with this maneuver. Care was taken not to try to do too much and jeopardize the neurovascular structures anteriorly. At that point, the wound was copiously irrigated and closure was initiated. The joint itself actually looked to be in good condition with no evidence of significant arthrosis.
Thanks