EHFcoding
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- Covina, CA
Hello everyone we would like a second coding opinion for the following op report. Thank you in advance.
Postoperative Diagnoses:
1. Left ankle fracture, closed, displaced with extensive comminution, shortening.
2. Syndesmotic joint disruption.
3. Torn medial collateral ligament with displaced deltoid ligament.
4. Displaced posterior tibial tendon.
5. Contracture of the anterior tibial tendon with severe adhesions due to abutment against large suspected mass.
6. Large mass or tumor of the anteromedial ankle measuring 7 cm x 4 cm, fibrous in nature.
Procedures Performed:
1. Complex open reduction and internal fixation of left bimalleolar ankle fracture.
2. Open treatment of distal tibiofibular joint disruption .
3. Excision of tumor deep subfacial .
4. Repair of deltoid ligament .
5. Tenolysis, intersection of posterior tibial tendon .
6. Tenolysis of the anterior tibial tendon .
Procedure In Detail: The patient was identified in the preoperative holding area. The operative site was marked by the surgical team. The patient was brought to the operating room where general endotracheal anesthesia was induced. The left lower extremity was prepped and draped in usual sterile fashion. A time-out was performed. A lateral incision was first made over the lateral malleolus extending proximally. This was taken through skin fat down to the level of the fascia. A hematoma was noted on approach, which was evacuated. Periosteal dissection was performed to expose the fracture site. The fracture site was noted to be in oblique fashion at the level of syndesmosis. Reduction clamps were used to reduce the fracture. At this time, the posterior tibial tendon was identified and was found to be translated anteriorly, an extensive tenosynovial inflammation around the tendon, therefore, the tendon was further isolated and dissected proximally and distally, released of any synovial adhesions and placed posteriorly and posterior to the fibula. Attention was then turned back to the fibula. The appropriate-sized plate was placed over the fibula and 2 screws were placed in appropriate fashion. Anteriorly, the fracture did extend into the tibiofibular syndesmosis and a retractor was placed anteriorly. The syndesmosis was reduced with a large reduction clamp and a larger screw was placed to capture tibial fixation and compress the tibiofibular syndesmosis. At this time, x-rays were taken to confirm appropriate alignment of fracture fixation. Therefore, at this time, the wounds were irrigated. The posterior tibial tenolysis was repaired with a 0 Vicryl suture to anchor the posterior tibial tendon within the posterior retinaculum. The deep layers were closed with 0 Vicryl and superficial layers were closed with 2-0 Vicryl and nylon sutures. Attention was then turned medially. There was noted to be a large mass at the anterior medial ankle. It was just distal to the tip of the medial malleolus. Working around the mass could have been possible, but with appropriate screw placement somewhat, it was difficult to achieve. Additionally, given the patient's family concerned regarding the mass, we elected to proceed with excision of the large mass for further evaluation. Therefore, the incision was extended distally. The mass was centered over the medial anterior talotibial joint. It was dissected with careful dissection and removed en bloc and measured to be about 7 cm x 4 cm and fibrous in nature. At this time, the wounds were thoroughly irrigated before further dissection down to the medial malleolus. Medial malleolus was identified and found to have fractured soft tissue fragments within fracture site. These were removed and the fracture was then reduced with reduction forceps. Appropriate-sized screws were placed in a cannulated screw fashion. It was noted at this time that the anterior tibial tendon was retracted and adhered in an abnormal position due to the abutment against the mass chronically. Therefore, the anterior tibial tendon was released with adhesions and tenolysis was performed. This freed the anterior tibial tendon into appropriate alignment. Attention then turned to the deltoid ligament, it was found to be torn distal to the medial malleolus as well. The deltoid ligament was sutured using 0 Vicryl sutures for repair. At this time, the wounds were thoroughly irrigated medially and closed with 0 Vicryl and 2-0 nylon. Sterile dressings were applied and a splint was applied. The patient will remain touch-down weightbearing for 6-8 weeks given his dementia status.
For coding purposes, this case warrants the use of 22 modifier. The patient presents with severe osteopenia due to the bony quality, which increased the difficulty of screw placement and fracture fixation and this increased the time, effort, surgical skill, surgical technique by greater than 100% and therefore, warrants the use of 22 modifier.
Radiology report findings prior to surgery:
Findings:
Acute transverse, mild-to-moderately displaced fracture of the medial
malleolus with acute avulsion fracture fragment measuring 3.0 cm. Acute,
mild-to-moderately displaced oblique fracture of the distal fibular
metadiaphysis with acute avulsion fracture fragment involving the lateral
malleolus measuring 4.7 cm with medial displacement of the proximal fracture
fragment by at least 1/2 shaft width. Described fractures demonstrate
intra-articular extension with disruption of the ankle mortise and dislocation
of the tibiotalar joint.
The talar dome is radiographically unremarkable. No osseous lesions are
identified. Demineralization is noted compatible with osteopenia/osteoporosis.
There are mild-to-moderate degenerative changes of the visualized portions of
the tibiotalar joint with suspected joint space narrowing, subchondral
sclerosis and small marginal osteophytes.. Moderate plantar calcaneal spurring
noted.
The soft tissues demonstrate soft tissue swelling with suspected tibiotalar
joint effusion and are otherwise unremarkable. Vascular calcifications are
noted.
Postoperative Diagnoses:
1. Left ankle fracture, closed, displaced with extensive comminution, shortening.
2. Syndesmotic joint disruption.
3. Torn medial collateral ligament with displaced deltoid ligament.
4. Displaced posterior tibial tendon.
5. Contracture of the anterior tibial tendon with severe adhesions due to abutment against large suspected mass.
6. Large mass or tumor of the anteromedial ankle measuring 7 cm x 4 cm, fibrous in nature.
Procedures Performed:
1. Complex open reduction and internal fixation of left bimalleolar ankle fracture.
2. Open treatment of distal tibiofibular joint disruption .
3. Excision of tumor deep subfacial .
4. Repair of deltoid ligament .
5. Tenolysis, intersection of posterior tibial tendon .
6. Tenolysis of the anterior tibial tendon .
Procedure In Detail: The patient was identified in the preoperative holding area. The operative site was marked by the surgical team. The patient was brought to the operating room where general endotracheal anesthesia was induced. The left lower extremity was prepped and draped in usual sterile fashion. A time-out was performed. A lateral incision was first made over the lateral malleolus extending proximally. This was taken through skin fat down to the level of the fascia. A hematoma was noted on approach, which was evacuated. Periosteal dissection was performed to expose the fracture site. The fracture site was noted to be in oblique fashion at the level of syndesmosis. Reduction clamps were used to reduce the fracture. At this time, the posterior tibial tendon was identified and was found to be translated anteriorly, an extensive tenosynovial inflammation around the tendon, therefore, the tendon was further isolated and dissected proximally and distally, released of any synovial adhesions and placed posteriorly and posterior to the fibula. Attention was then turned back to the fibula. The appropriate-sized plate was placed over the fibula and 2 screws were placed in appropriate fashion. Anteriorly, the fracture did extend into the tibiofibular syndesmosis and a retractor was placed anteriorly. The syndesmosis was reduced with a large reduction clamp and a larger screw was placed to capture tibial fixation and compress the tibiofibular syndesmosis. At this time, x-rays were taken to confirm appropriate alignment of fracture fixation. Therefore, at this time, the wounds were irrigated. The posterior tibial tenolysis was repaired with a 0 Vicryl suture to anchor the posterior tibial tendon within the posterior retinaculum. The deep layers were closed with 0 Vicryl and superficial layers were closed with 2-0 Vicryl and nylon sutures. Attention was then turned medially. There was noted to be a large mass at the anterior medial ankle. It was just distal to the tip of the medial malleolus. Working around the mass could have been possible, but with appropriate screw placement somewhat, it was difficult to achieve. Additionally, given the patient's family concerned regarding the mass, we elected to proceed with excision of the large mass for further evaluation. Therefore, the incision was extended distally. The mass was centered over the medial anterior talotibial joint. It was dissected with careful dissection and removed en bloc and measured to be about 7 cm x 4 cm and fibrous in nature. At this time, the wounds were thoroughly irrigated before further dissection down to the medial malleolus. Medial malleolus was identified and found to have fractured soft tissue fragments within fracture site. These were removed and the fracture was then reduced with reduction forceps. Appropriate-sized screws were placed in a cannulated screw fashion. It was noted at this time that the anterior tibial tendon was retracted and adhered in an abnormal position due to the abutment against the mass chronically. Therefore, the anterior tibial tendon was released with adhesions and tenolysis was performed. This freed the anterior tibial tendon into appropriate alignment. Attention then turned to the deltoid ligament, it was found to be torn distal to the medial malleolus as well. The deltoid ligament was sutured using 0 Vicryl sutures for repair. At this time, the wounds were thoroughly irrigated medially and closed with 0 Vicryl and 2-0 nylon. Sterile dressings were applied and a splint was applied. The patient will remain touch-down weightbearing for 6-8 weeks given his dementia status.
For coding purposes, this case warrants the use of 22 modifier. The patient presents with severe osteopenia due to the bony quality, which increased the difficulty of screw placement and fracture fixation and this increased the time, effort, surgical skill, surgical technique by greater than 100% and therefore, warrants the use of 22 modifier.
Radiology report findings prior to surgery:
Findings:
Acute transverse, mild-to-moderately displaced fracture of the medial
malleolus with acute avulsion fracture fragment measuring 3.0 cm. Acute,
mild-to-moderately displaced oblique fracture of the distal fibular
metadiaphysis with acute avulsion fracture fragment involving the lateral
malleolus measuring 4.7 cm with medial displacement of the proximal fracture
fragment by at least 1/2 shaft width. Described fractures demonstrate
intra-articular extension with disruption of the ankle mortise and dislocation
of the tibiotalar joint.
The talar dome is radiographically unremarkable. No osseous lesions are
identified. Demineralization is noted compatible with osteopenia/osteoporosis.
There are mild-to-moderate degenerative changes of the visualized portions of
the tibiotalar joint with suspected joint space narrowing, subchondral
sclerosis and small marginal osteophytes.. Moderate plantar calcaneal spurring
noted.
The soft tissues demonstrate soft tissue swelling with suspected tibiotalar
joint effusion and are otherwise unremarkable. Vascular calcifications are
noted.