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ORIF for distal radius and ulna fx.

  1. #1
    Fort Worth, Texas
    Default ORIF for distal radius and ulna fx.
    Medical Coding Books
    Need opinion please. The attached Op note states distal radius and ulna fx. but when I reviewed I am only seeing one fracture documented. Am I missing something.

    Thank you for any help
    Leslie, CPC

    PREOPERATIVE DIAGNOSIS: Left distal radius and ulna fracture.

    POSTOPERATIVE DIAGNOSIS: Left distal radius and ulna fracture.

    OPERATION PERFORMED: Open reduction and internal fixation, left distal radius
    and ulna, with volar plate.

    ANESTHESIA: General.

    ESTIMATED BLOOD LOSS: Less than 100 mL.


    SURGICAL FINDINGS: Patient was found to have a severely comminuted distal
    radius fracture as anticipated, which was reducible but very unstable.

    REPORT OF OPERATION: Patient was brought to the operating suite, and after a
    satisfactory general anesthetic had been administered, the splint was removed
    from the left upper extremity. The skin was in good condition. There was
    anticipated swelling and early ecchymosis. Tourniquet was applied to the left
    upper arm. The left upper arm, forearm, and hand were prepped and draped in
    usual sterile fashion. After gravity exsanguination, tourniquet was elevated.
    Fluoroscopy was used to determine the possibility of reduction, and it was
    found that that was possible but, of course, immediate collapse occurred as
    soon as the reduction force was removed. An incision was made along the flexor
    carpi radialis tendon and at the distal wrist crease, carried tangentially
    radially onto the thenar eminence. This was taken down through the
    subcutaneous tissues, identifying the tendon. The tendon was then retracted
    radially, protecting the neurovascular bundle, and dissection was carried
    further down through the flexor tendon to the fracture, which had torn the
    muscle. The muscle was detached proximally so that it could be dissected away,
    and Homan retractors were placed. The fracture was thoroughly irrigated to
    remove the clot. The fracture was then placed in the reduced position with
    reduction force and a volar plate was selected. Two pins were placed and
    initial x-rays were taken. The sliding screw hole was used to place a screw,
    and then the plate was positioned under fluoroscopic control to provide optimum
    stabilization. The screw was then tightened into place. Seven screws locking
    were then placed into the distal aspect of the plate to hold the multiple
    fragments in acceptable position. After this was done, the remaining large
    screw in the volar plate was placed. Final images demonstrated reduction as
    anticipated. As the wrist was placed through range of motion under
    fluoroscopy, the fragments remained in position. Thorough irrigation was then
    done. The flexor volar surface was repaired with interrupted 2-0 Vicryl,
    subcutaneous tissue closed with interrupted 2-0 Vicryl. Skin was closed with 3-
    0 nylon. Marcaine was injected along the skin edge for postoperative
    analgesia. A sterile dressing with a volar splint was then applied. With the
    tourniquet released, all the fingers pinked immediately. Patient was awakened
    and taken to the recovery area in stable condition, having tolerated the
    procedure well.

  2. #2
    I usually let the Doctor verify the op note if there is something missing before i code. The title of the procedure in the op note should match the body of the op note.

  3. #3
    The surgical findings say "severely comminuted distal radius fracture as anticipated" This report reads like a 25608 or 25609, in my opinion, however it still needs to be clarified by the surgeon.

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