joanne71178
Guru
DIAGNOSIS: Repair Distal Biceps & brachioradialis muscle laceration
INDICATION FOR SURGERY:
'This is a 51-year old gentle man who was driving a motorcycle in gravel and went off the road into barbed wire fence sustaining a deep laceration to the left elbow. He was transported to Santa Barbara Cottage Hospital for vascular workup which was negative. Due to lack of operating room availability, he was scheduled for outpatient exploration and repair of muscles. He had an MRI scan performed which showed close to less than 50% laceration of biceps and brachioradialis and slightly more than 50% laceration of brachioradialis muscles. He was admitted for treatment.'
FINDINGS AND PROCEDURE:
'The patient was brought to the operating room. After a general anesthetic was induced following an interscalene block, the lft upper extremity was prepped and draped in sterile orthopedic fashion. The nylon sutures were removed from the transverse antecubital laceration. The arm was prepped and draped in sterile orthopedic fashion. Cultures were obtained from the wound which had no evidence of ross infection, although there was erythema at the wound margins and inflammation. After prepping and draping, the wound was explored revealing a laceration of more than 50% of the brachioradialis as seen on the MRI scan and approximately 30-40% of the biceps muscle with fascial laceration. There was a question of an anterior loose body in the soft tissues which was not seen on plain x-ray or MR artifact which was not localized.
After through irrigation with normal saline and double antibiotic solution with pulsatile lavage, 0 Vicryl and 2-0 Vicryl were used to close muscle and fascial layers in the brachioradialis muscle and biceps muscle and fascia. The skin layer was closed with 2-0 nylon mattress sutures. A sterile compressive dressing was applied followed by a posterior splint. ...."
I want to get a second opinion on the codes I chose. The doctor is Out of Network/Non-Par w/the patients insurance.
881.11, E816.2
11043 LT
24341 LT
Any comments are much appreciated.
Thanks in advance!
INDICATION FOR SURGERY:
'This is a 51-year old gentle man who was driving a motorcycle in gravel and went off the road into barbed wire fence sustaining a deep laceration to the left elbow. He was transported to Santa Barbara Cottage Hospital for vascular workup which was negative. Due to lack of operating room availability, he was scheduled for outpatient exploration and repair of muscles. He had an MRI scan performed which showed close to less than 50% laceration of biceps and brachioradialis and slightly more than 50% laceration of brachioradialis muscles. He was admitted for treatment.'
FINDINGS AND PROCEDURE:
'The patient was brought to the operating room. After a general anesthetic was induced following an interscalene block, the lft upper extremity was prepped and draped in sterile orthopedic fashion. The nylon sutures were removed from the transverse antecubital laceration. The arm was prepped and draped in sterile orthopedic fashion. Cultures were obtained from the wound which had no evidence of ross infection, although there was erythema at the wound margins and inflammation. After prepping and draping, the wound was explored revealing a laceration of more than 50% of the brachioradialis as seen on the MRI scan and approximately 30-40% of the biceps muscle with fascial laceration. There was a question of an anterior loose body in the soft tissues which was not seen on plain x-ray or MR artifact which was not localized.
After through irrigation with normal saline and double antibiotic solution with pulsatile lavage, 0 Vicryl and 2-0 Vicryl were used to close muscle and fascial layers in the brachioradialis muscle and biceps muscle and fascia. The skin layer was closed with 2-0 nylon mattress sutures. A sterile compressive dressing was applied followed by a posterior splint. ...."
I want to get a second opinion on the codes I chose. The doctor is Out of Network/Non-Par w/the patients insurance.
881.11, E816.2
11043 LT
24341 LT
Any comments are much appreciated.
Thanks in advance!
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