The provider coded this visit with a deleted code (25620). I think this should be 25607 and 25652. Can you guys take a gander and check behind me?
PREOPERATIVE DIAGNOSIS: Displaced, unstable left distal radius and ulna fracture.
POSTOPERATIVE DIAGNOSIS: Displaced, unstable left distal radius and ulna fracture.
PRINCIPAL PROCEDURE: Open reduction internal fixation, left wrist.
A standard incision centered over the radial aspect of the wrist just on the radial side of the flexor carpi radialis was performed. Care was taken to protect and locate the radial artery. The pronator quadratus was gently reflected off the radial aspect of the distal radius exposing the fracture site. The patient had a comminuted fracture of the distal radius and ulnar. A reduction was performed. Using the Synthes extra articular locking plate from the distal radius set, the fracture was secured using a combination of cortical screws and locking screws proximally as well as cortical screws and locking screws distally. Satisfactory reduction and stability was noted. Intraoperative x-rays in the C arm including motion views in the C arm demonstrates satisfactory alignment of the hardware, fracture in stability. The wounds were then irrigated, tourniquet deflated. No active bleeding note. Palpable radial pulse. The soft tissues were closed with 2-0 Vicryl and 3-0 nylon.
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