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any suggestions on this - extremity was marked

  1. #1
    Default any suggestions on this - extremity was marked
    Medical Coding Books
    PREOPERATIVE DIAGNOSIS: Grade 3 right acromioclavicular separation.

    POSTOPERATIVE DIAGNOSIS: Grade 3 right acromioclavicular separation.

    PROCEDURE: Repair of right coracoclavicular ligaments with Arthrex TightRope.

    ANESTHESIA: General with interscalene block.

    DESCRIPTION OF PROCEDURE: The patient was identified preoperatively. The right upper extremity was marked. An interscalene block was administered by Anesthesia staff. The patient was then taken to the operating room and placed on the table in the supine position. General anesthesia was obtained. He was then brought to the beach chair position. The right shoulder and arm were prepped and draped free in a standard sterile fashion. An anterior skin incision was made vertically from the coracoid process to the clavicle. The subcutaneous tissue was divided. The deltoid was dissected free and retracted laterally. The coracoid was identified and cleared of fascia. The torn CC ligaments could be seen. The deltotrapezial fascia was then split over the clavicle, and the clavicle freed. Using the Arthrex guide system, a guidewire was placed, and a 4 mm hole drilled in the clavicle and down through the coracoid. Care was taken to protect the neurovascular structures. A guidewire was then passed and grasped with a hemostat and brought out. The TightRope was passed, and then the clavicle reduced and the sutures tightened down very securely. This gave what appeared to be complete reduction of the injury. The wound was irrigated copiously. The deltotrapezial fascia was closed with 0 Ethibond. The subcutaneous was closed with 2-0 Vicryl and 4-0 Monocryl. A sterile compressive dressing and sling was applied. The anesthetic was discontinued, and the patient was taken to the recovery room in excellent condition. There were no complications.

  2. #2
    My first take was 23415 ,nonetheless, the anthrex guide system is left out. I therefore chose to go with unlisted procedure, shoulder 23929, to encompass the Anthrex guide system.
    You would definitely need to send documentation to support procedure.

    I'm curious to see other suggestions.

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