PIP fracture Dislocation Surgery report help

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Lawrence Ks
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Please help advise me on this procedure. My physician likes to review his surgery coding before they get submitted to insurance and approved the codes billed out. He does this procedrue quite frequently and we always use 26535, Same diagnosis, same procedure. He is now wanting me to use 26746 on this one stating we are treating the fracture not arthritis. I would love some feedback on if you agree with his choice.




PRE-OP DIAGNOSIS: Right ring finger PIP fracture dislocation

POST-OP DIAGNOSIS: Same

OPERATION PERFORMED: Right ring finger hemi-hamate arthroplasty

ANESTHESIA: General

PROCEDURE INDICATION: The patient is a 28-year-old female who sustained a fracture dislocation of her right ring finger in a MVA. The risks, benefits, and possible complications of surgery were discussed. Nonoperative options were discussed. Questions were answered. Informed consent was obtained. The patient wished to proceed with operative treatment. Indication for surgery included unstable fracture dislocation at the PIP.

PROCEDURE DESCRIPTION: The patient and the surgeon marked the operative site. The patient was administered perioperative antibiotics. The patient was taken to the operating room and appropriate timeouts were taken. The right upper extremity was sterilely prepped and draped, after the patient was administered general anesthesia. The landmarks were palpated and a Bruner incision was marked over the volar small finger. Bipolar electrocautery was used for hemostasis. Full thickness flaps were developed. The neurovascular bundles were identified and protected. The flexor sheath was exposed and opened between the A2 and A4 pulleys. The volar plate was teased off its distal insertion. The collateral ligaments were excised. The flexor tendons were retracted and the joint was opened in a shotgun fashion. The fracture was identified and had almost a dye punch component to it, about 2-3 in diameter. The fractured area was then debrided out to create a bed for the graft and the joint was relocated after creating this bed.

Attention was turned to the dorsoulnar hand, and an incision was marked and made over the fourth and fifth CMCs. Bipolar electrocautery was used for hemostasis. Careful spreading dissection was carried down. The capsule was opened. The graft was marked out having taken measurements of the defect and the graft was then harvested using osteotomes. The wound here was irrigated and the capsule was repaired over this. The wound was closed in layers. The graft was then trimmed using the osteotomes and a bur and contoured to fit into position and secured with two 1.3 mm. screws with excellent purchase. Fluoroscopy confirmed good position of the graft, good stability of the PIP joint. Direct inspection showed a nice congruous articular surface.

The wound was irrigated. The volar plate was repaired. The wound was closed. The digit was blocked with Marcaine. Dressing and a splint were applied and the tourniquet was released. The patient was taken to the recovery room in stable condition. She tolerated the procedure well. There were no complications. There were no specimens. Findings included a fracture at the base of the middle phalanx.

Fluoroscopic images taken during the case confirmed good position of the graft, good stability of the joint, good position of the hardware.


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