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I need help finding a procedure code.
PREOPERATIVE DIAGNOSIS: Status post right leg fasciotomy.
POSTOPERATIVE DIAGNOSIS: Status post right leg fasciotomy.
PROCEDURE PERFORMED: Exploration of previous fasciotomy site
with rubber band dermoplasty right leg.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CONDITION ON ARRIVAL TO POST ANESTHESIA CARE UNIT: Stable.
GROSS FINDINGS ON PREOP EVALUATION OF THE RIGHT LEG:
The patient had previously undergone a fasciotomy of the right
leg. The wound was found to be clean, dry and intact. No
drainage from the wound. No evidence of infection. The
fasciotomy was reopened with blunt dissection today, irrigation
performed and a new rubber band dermoplasty applied.
OPERATIVE REPORT:
After identification of the patient in the preoperative holding
area and marking his lower extremities, the patient was taken to
the operative suite and placed in a flat supine position on the
operating table. After adequate anesthesia was obtained, the
right lower extremity was sterilely prepped and draped in the
usual fashion for lower extremity leg surgery. At this time
exploration of the wound was performed with blunt dissection
utilizing the blunt Yankauer tip, opening again of the fasciotomy
sites were made. The calf was found to be soft. The wound was
then copiously irrigated with saline and dried at this time.
Adaptic was applied to the wound. Rubber band dermoplasty was
performed. The wound was then dressed with 4 x 4s, an ABD chest
padding and an Ace wrap from the toes to the knee. The patient
was then awakened from anesthesia and taken to recovery in
satisfactory condition. The patient tolerated the procedure well
and was transferred to the Post Anesthesia Care Unit in
satisfactory condition.
PREOPERATIVE DIAGNOSIS: Status post right leg fasciotomy.
POSTOPERATIVE DIAGNOSIS: Status post right leg fasciotomy.
PROCEDURE PERFORMED: Exploration of previous fasciotomy site
with rubber band dermoplasty right leg.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
CONDITION ON ARRIVAL TO POST ANESTHESIA CARE UNIT: Stable.
GROSS FINDINGS ON PREOP EVALUATION OF THE RIGHT LEG:
The patient had previously undergone a fasciotomy of the right
leg. The wound was found to be clean, dry and intact. No
drainage from the wound. No evidence of infection. The
fasciotomy was reopened with blunt dissection today, irrigation
performed and a new rubber band dermoplasty applied.
OPERATIVE REPORT:
After identification of the patient in the preoperative holding
area and marking his lower extremities, the patient was taken to
the operative suite and placed in a flat supine position on the
operating table. After adequate anesthesia was obtained, the
right lower extremity was sterilely prepped and draped in the
usual fashion for lower extremity leg surgery. At this time
exploration of the wound was performed with blunt dissection
utilizing the blunt Yankauer tip, opening again of the fasciotomy
sites were made. The calf was found to be soft. The wound was
then copiously irrigated with saline and dried at this time.
Adaptic was applied to the wound. Rubber band dermoplasty was
performed. The wound was then dressed with 4 x 4s, an ABD chest
padding and an Ace wrap from the toes to the knee. The patient
was then awakened from anesthesia and taken to recovery in
satisfactory condition. The patient tolerated the procedure well
and was transferred to the Post Anesthesia Care Unit in
satisfactory condition.