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Hand sx

  1. #1
    Question Hand sx
    Medical Coding Books
    I was hoping to get some help with the following op note:

    Post OP Dx: 1.Traumatic laceration of profundus and superficialis muscles to the tendon of the fifth digit on left.
    2. Traumatic laceration greater than 5 cm of pt's left hand on the volar side.
    3. Traumatic laceration of the pt's carpal tunnel, specifically transverse carpal ligament left side.

    Procedure: 1. Tenorrhaphy of pt's flexor tendon to fifth digit profundus.
    2. Tenolysis of pt's flexor tendon to fifth digit superficialis.
    3. Carpal tunnel release
    4. Flexor tendon tenolysis of synovium to all tendons x10
    5. I&D of traumatic laceration of hand/deep
    6. Primary repair of 5-cm traumatic laceration w/extension

    ...the stitches were removed from the ER and the wound was explored. It was essential to explore the wound a bit further down to the crease of the wrist and slightly proximal as well. The original laceration was a T-type laceration about 5-6 cm in length. Further dissection carried this down to carpal tunnel which was partially transversed immediately while the median nerve was well intact.
    At this point, the remainder of the pt's carpal tunnel ligament was then subsequently released so that I could visualize each of the existing tendons. Tenolysis was perforned of each of the tendons of the synovium. This was necessary to assess each tendon function and trauma.
    After we noted immediately the pt's superficialis and profundus tendons to the fifth digit were partially lacerated with required repair w/a monofilament sutre of 4-0 size as well as debridement of the actual profundus tendon which was not repairable at all, yet still intact. Based on this after repairing and performing the debridement, irrigated out copiously with antibiotic solution...

    Can anyone help me with this. I normally do not code hand procedures and I am a little lost on this one.

    Thanks in advance for any help you can give!

  2. #2
    did you get this one yet Cathy? Sorry I've been buried and havent been here in a few days. If not, give me a buzz and we can go over it together.

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