maryir
Networker
Hello everyone,
Please review the note below. I coded this as a 27792 but was told I was incorrect.
I'm being advised to "correct" the coding to code the service as a 27814 (stating "Based upon review of op report, patient had B lateral malleolar fracture which was repaired medially and laterally").
I used a 27792 because the note is stating the patient had a bimalleolar equivalent fracture and an attempt was made to reduce it laterally but was unsuccessful. Am I looking at it wrong??
I have to either correct the code or be ready to defend my reasoning.
PREOPERATIVE DIAGNOSIS: Right bimalleolar ankle fracture.
POSTOPERATIVE DIAGNOSIS: Right bimalleolar ankle fracture.
PROCEDURE PERFORMED: Open reduction internal fixation of right bimalleolar ankle fracture.
IMPLANTS: Synthes 1/3 tubular plate, 7 hole; and six 3.5 cortical screws.
**
INDICATIONS FOR PROCEDURE: ...after he sustained a right bimalleolar ankle fracture approximately 10 days previous. The patient states he was given a new splint on xx and was scheduled for surgery. The patient was lost to followup prior to surgery and surgery had to be rescheduled but was able to be scheduled appropriately for xx. On imaging, the patient had a bimalleolar equivalent right ankle fracture with an oblique fracture of the right lateral malleolus with widening of the syndesmosis. It was discussed with the patient that given the character of the fracture pattern that his ankle was unstable and needed surgical fixation. The patient was understanding and informed consent was signed.
**
PROCEDURE IN DETAIL: The patient was identified in the preoperative area and the operative extremity was marked. A regional block was placed by the anesthesia service in the right lower extremity. The patient was brought into the operating theater and he was placed supine on the operating table. General anesthesia was induced. The patient was intubated. The patient's splint was removed and the patient's right lower extremity was draped in the normal sterile fashion. A timeout was performed and the procedure was begun. Incision was made over the fibula down through subcutaneous tissues, careful to protect the superficial peroneal nerve. This was brought down to the bone. Fracture was identified. Given the patient is approximately 3 weeks
status post his injury, the fracture was noted to show signs of healing with some callus within the fracture itself. The fracture was booked open and the ends of the fracture were cleared out appropriately. Reduction of the fracture was attempted; however, we were unable to get reduction that was of appropriate alignment. We then moved to the medial aspect of the ankle. An incision was made over the medial malleolus down to the level of bone.
**
We moved our attention to the anterior aspect of the medial malleolus and cleared out the callus that was in the medial clear space area. After this callus was appropriately removed, on imaging, we were able to more appropriately close down the medial clear space and his lateral malleolus fracture was more mobile. Reduction was obtained and held in place by point-to-point clamp. Alignment was confirmed using x-ray. We then placed a 7-hole plate on the posterior aspect of the fibula and confirmed
placement of the plate on x-ray. The plate was held with an alligator clamp and the first 3.5 cortical screw was placed in buttress mode. We then placed by lag by technique screws from posterior to anterior position through the fracture through the plate. We used another clamp to keep the fracture appropriately compressed with the plate in place. We then filled the remaining usable holes in the plate with cortical screws. At this time, we then stressed the ankle and showed there is no opening and now had stabilization of the syndesmosis. Both the medial and lateral wounds were appropriately irrigated and final images were taken.
**
Deep fascia was closed with 0 Vicryl, subcutaneous tissue with 2-0 Vicryl and the skin with 3-0 nylon. The patient was cleaned and was placed in a short leg splint.
**
CONDITION: The patient was awoken without any issues in the operating theater by anesthesia. He was transferred to the PACU without any issues.
Please review the note below. I coded this as a 27792 but was told I was incorrect.
I'm being advised to "correct" the coding to code the service as a 27814 (stating "Based upon review of op report, patient had B lateral malleolar fracture which was repaired medially and laterally").
I used a 27792 because the note is stating the patient had a bimalleolar equivalent fracture and an attempt was made to reduce it laterally but was unsuccessful. Am I looking at it wrong??
I have to either correct the code or be ready to defend my reasoning.
PREOPERATIVE DIAGNOSIS: Right bimalleolar ankle fracture.
POSTOPERATIVE DIAGNOSIS: Right bimalleolar ankle fracture.
PROCEDURE PERFORMED: Open reduction internal fixation of right bimalleolar ankle fracture.
IMPLANTS: Synthes 1/3 tubular plate, 7 hole; and six 3.5 cortical screws.
**
INDICATIONS FOR PROCEDURE: ...after he sustained a right bimalleolar ankle fracture approximately 10 days previous. The patient states he was given a new splint on xx and was scheduled for surgery. The patient was lost to followup prior to surgery and surgery had to be rescheduled but was able to be scheduled appropriately for xx. On imaging, the patient had a bimalleolar equivalent right ankle fracture with an oblique fracture of the right lateral malleolus with widening of the syndesmosis. It was discussed with the patient that given the character of the fracture pattern that his ankle was unstable and needed surgical fixation. The patient was understanding and informed consent was signed.
**
PROCEDURE IN DETAIL: The patient was identified in the preoperative area and the operative extremity was marked. A regional block was placed by the anesthesia service in the right lower extremity. The patient was brought into the operating theater and he was placed supine on the operating table. General anesthesia was induced. The patient was intubated. The patient's splint was removed and the patient's right lower extremity was draped in the normal sterile fashion. A timeout was performed and the procedure was begun. Incision was made over the fibula down through subcutaneous tissues, careful to protect the superficial peroneal nerve. This was brought down to the bone. Fracture was identified. Given the patient is approximately 3 weeks
status post his injury, the fracture was noted to show signs of healing with some callus within the fracture itself. The fracture was booked open and the ends of the fracture were cleared out appropriately. Reduction of the fracture was attempted; however, we were unable to get reduction that was of appropriate alignment. We then moved to the medial aspect of the ankle. An incision was made over the medial malleolus down to the level of bone.
**
We moved our attention to the anterior aspect of the medial malleolus and cleared out the callus that was in the medial clear space area. After this callus was appropriately removed, on imaging, we were able to more appropriately close down the medial clear space and his lateral malleolus fracture was more mobile. Reduction was obtained and held in place by point-to-point clamp. Alignment was confirmed using x-ray. We then placed a 7-hole plate on the posterior aspect of the fibula and confirmed
placement of the plate on x-ray. The plate was held with an alligator clamp and the first 3.5 cortical screw was placed in buttress mode. We then placed by lag by technique screws from posterior to anterior position through the fracture through the plate. We used another clamp to keep the fracture appropriately compressed with the plate in place. We then filled the remaining usable holes in the plate with cortical screws. At this time, we then stressed the ankle and showed there is no opening and now had stabilization of the syndesmosis. Both the medial and lateral wounds were appropriately irrigated and final images were taken.
**
Deep fascia was closed with 0 Vicryl, subcutaneous tissue with 2-0 Vicryl and the skin with 3-0 nylon. The patient was cleaned and was placed in a short leg splint.
**
CONDITION: The patient was awoken without any issues in the operating theater by anesthesia. He was transferred to the PACU without any issues.
