I'm looking for oppinions on how you would code the anesthesia service for the following procedure:
PREOPERATIVE DIAGNOSIS:
Delayed union to a right humerus with gross motion and pain.
POSTOPERATIVE DIAGNOSIS:
Delayed union to a right humerus with gross motion and pain.
OPERATION PERFORMED:
1. Open reduction and internal fixation right humerus fracture with an 8 hole large fragment set Synthes plate with a periarticular fracture cerclage cables superiorly, 4.5 cortical screws distally.
SUMMARY OF HISTORY AND PHYSICAL:
This patient was slightly confused in the evening and fell leading to a fracture at the tip of a total shoulder that had been in place for several
years. She was tried on conservative care, but had very little motion, very little healing, and marked motion at the fracture site at 4 weeks out with no x-ray evidence of healing and a great deal of discomfort. I explained to her fully the risks, possible complications, and limitations of surgical itervention. Fully aware of the risks, possible complications, and limitations of the procedure. The patient chose to have procedure performed, signed the operative permit.
DESCRIPTION OF PROCEDURE:
The patient brought to the operating room where a general anesthetic was administered. The area of the right upper extremity prepped and draped in sterile fashion. Operation began with placement of a skin incision following her shoulder incision at the deltopectoral groove down to the lateral border of the biceps. The humerus was then fully exposed. Periosteum was left intact as much as possible. Fracture was then reduced and 3 Synthes cables were placed proximally through an 8 hole DCP plate. Once these were moderately tightened, a 4.5 cortical screw was placed in compression mode giving good compression at the fracture. The wires were then tightened securely followed by 2 more distal screws. Once this was done, a strut allograft was placed medially. It was bone graft with autograft, allograft, and Osteonics DBX, and secured with 2 more Synthes cables. Once this was done, the wound was copiously irrigated out. The deep fascia was closed with running stitch of #2Vicryl. Subcutaneous tissue closed with interrupted stitches of #2 Vicryl. Skin closed with skin clips. Sterile dressing of Aquacel, sterile Kerlix, and Ace wrap applied, and the patient taken to the postanesthesia care area without surgical complication.
ANY input would be appreciated.
PREOPERATIVE DIAGNOSIS:
Delayed union to a right humerus with gross motion and pain.
POSTOPERATIVE DIAGNOSIS:
Delayed union to a right humerus with gross motion and pain.
OPERATION PERFORMED:
1. Open reduction and internal fixation right humerus fracture with an 8 hole large fragment set Synthes plate with a periarticular fracture cerclage cables superiorly, 4.5 cortical screws distally.
SUMMARY OF HISTORY AND PHYSICAL:
This patient was slightly confused in the evening and fell leading to a fracture at the tip of a total shoulder that had been in place for several
years. She was tried on conservative care, but had very little motion, very little healing, and marked motion at the fracture site at 4 weeks out with no x-ray evidence of healing and a great deal of discomfort. I explained to her fully the risks, possible complications, and limitations of surgical itervention. Fully aware of the risks, possible complications, and limitations of the procedure. The patient chose to have procedure performed, signed the operative permit.
DESCRIPTION OF PROCEDURE:
The patient brought to the operating room where a general anesthetic was administered. The area of the right upper extremity prepped and draped in sterile fashion. Operation began with placement of a skin incision following her shoulder incision at the deltopectoral groove down to the lateral border of the biceps. The humerus was then fully exposed. Periosteum was left intact as much as possible. Fracture was then reduced and 3 Synthes cables were placed proximally through an 8 hole DCP plate. Once these were moderately tightened, a 4.5 cortical screw was placed in compression mode giving good compression at the fracture. The wires were then tightened securely followed by 2 more distal screws. Once this was done, a strut allograft was placed medially. It was bone graft with autograft, allograft, and Osteonics DBX, and secured with 2 more Synthes cables. Once this was done, the wound was copiously irrigated out. The deep fascia was closed with running stitch of #2Vicryl. Subcutaneous tissue closed with interrupted stitches of #2 Vicryl. Skin closed with skin clips. Sterile dressing of Aquacel, sterile Kerlix, and Ace wrap applied, and the patient taken to the postanesthesia care area without surgical complication.
ANY input would be appreciated.