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Ankle help

  1. #1
    Default Ankle help
    Medical Coding Books
    Does anyone have advice for coding the following procedure:

    Standard longitudinal incision was made in a hockey stick fashion over the course of the posterior tib. An incision was made and we unroofed the FDL tendon, could not palpate the posterior tib and realized it was encased in bone. We dissected a bit more ditally, found the posterior tib tendon and working backwards removed the large encasement of bone over the top of the tendon. We found the posterior tib tendon and noted that it was encased in bone. It had adhesions to the underlying boney bed where the sheath had been violated. There was no synovial lining. It was up against bone. We smoothed the tendon down, relieving it and then found that the underlying bone was also abnormal and loose. We removed this piece as well. We did not decrease the integrity of the deltoid ligament. It was still intact. We removed this deep bone which was in 2 pieces, and after doing so the tendons moved freely. They did not need any sort of repair.

  2. Default
    The doctor didn't give you an operation performed on his dictation? Query him and explain to him that this helps you in getting to the right code.

    Just my thoughts!

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