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elbow fracture/dislocation

  1. #1
    Columbus, Ohio
    Smile elbow fracture/dislocation
    Medical Coding Books
    Hello coders, when the dx is both fracture and dislocation of the elbow, is it possible to bill an open reduction of both the fracture and dislocation? I've attached an op note where the surgeon states open treatment of fracture and dislocation. When I read the notes, I see only the fracture reduction with repair of the lateral collateral ligament. I was going to use 24575 and 24343. If I code a dislocation 24615 then the 24343 bundles. What am I not seeing when I read this? Thanks for all your help, Paula

    1. Open treatment, left elbow fracture dislocation.
    2. Open treatment, left lateral epicondyle fracture with internal fixation.
    3. Left elbow repair, lateral collateral ligament.

    The arm very easily popped out at 30 degrees of extension, this was very unstable. My decision at that point was to first try to repair the lateral epicondyle. I made a small incision over the lateral epicondyle. The skin was incised with a scalpel. Blunt retractor was placed in the wound. All hemostasis obtained throughout the case with Bovie. Blunt dissection was taken down to the extensor mass.

    There was an obvious tear in the extensor mass with lateral
    epicondyle displaced. I elevated the piece and freshened up the area of
    fracture with curettes and irrigation. At this time, I could see the lateral
    collateral ligament that was avulsed as well with a small piece of bone, this
    was not attached to the epicondyle. At this point, I placed a #2 FiberWire
    stitch through the lateral epicondyle and made drill holes around where the
    insertion would be. I made a bony bridge to tie this over. I used a Houston
    suture passer to pass the FiberWire through and would tie this after repairing
    the lateral epicondyle. I also placed a #2 FiberWire in a whipstitch manner
    through the forearm extensors to gain control of the fragment. I reduced the
    fragment using the suture and viewed this under fluoroscopy, this appeared to be satisfactory.
    I put one K-wire into the fragment where my screw is going
    to go and I put another K-wire in the fragment as a derotational wire. This
    was viewed under fluoroscopy and felt to have good position of the piece with
    good alignment. I measured the screw, the screw measured 35 mm. I chose a
    4.0 partially threaded cannulated cancellous screw with a washer. I drilled
    over the K-wire then placed in the screw over the K-wire compressing the
    fragment nicely, this held this very nicely. The screw actually did penetrate
    the posterior cortex with a good purchase. I removed the wires. There was
    anatomic position of the epicondyle. I then now tightened up my FiberWire for
    the lateral collateral ligament and tied this down over the bony bridge. At
    this point, I removed the arm through range of motion, this was very stable.
    I took the patient's arm through 130 degrees of flexion to 0 degrees of
    extension. The arm was very stable and there was no dislocation or
    subluxation. At that point, I did not feel it was necessary to address the
    medial side. The wound was copiously irrigated out with normal saline. Deep
    tissues were closed with 0 Vicryl. Vita-Gel soft tissue autograft processed
    from the patient's blood for postop hemostasis and potential healing was
    injected deeply. Skin was approximated with 2-0 Vicryl, this approximated the
    skin well. Steri-Strips and Mastisol were applied. Local anesthetic was
    injected. A sterile dressing was applied as well as a well-padded posterior
    splint with a sugar tong. Tourniquet was released. The patient was awoken
    from anesthesia without complication and transferred to the post anesthesia
    care unit in stable condition.

  2. #2
    Charm City - Baltimore
    I would use the 24575 and the 24343. But when I use 2009 CodeX to check the 24343 and 24615 I am not seeing that 24343 is bundled within 24615. It seems to be separately reportable with appropriate modifier.
    Crystal, CPC, CCS-P

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