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help coding operative

  1. #1
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    NEW ORLEANS
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    Default help coding operative
    Medical Coding Books
    would cpt code 28299 / with 28285 x2 and 28270 be the right choice not sure ,and do I USE L8699 FOR THE IMPLANTS-SCREWS?

    POSTOPERATIVE DIAGNOSES: 1. Severe hallux abdductovalgus deformity with a wide

    intermetatarsal angle, left foot. 2. Contracted joint of the second metatarsophalangeal joint, left foot. 3. Severe contraction of the metatarsophalangeal joint. 4. Hammertoe of the second toe second metatarsophalangeal joint, left foot.

    OPERATION: 1. Correction of the medial longitudinal arch and fusion of the first cuneiform with a 2.7 mm standard cloverleaf plate, Synthes. 2. Tenotomy of the second metatarsophalangeal joint, left foot. 3. Capsulotomy of the second metatarsophalangeal joint, left foot. 4. Arthroplasty of the second toe, left foot.

    PATHOLOGY: Soft tissue and bone.
    HARDWARE IMPLANT: 2.7 mm cloverleaf plate., (2) 2.7mm x 20mm,(1) 2.7 mm x 30 mm, (1) 2.7 mm x 40mm, (2) 2.7 mm x 30 mm locking screw.
    DRAIN: Penrose drain.

    The patient was noted to have a severe deformity. The patient had an intermetatarsal angle of more than 40 degrees or more. The patient could not put any pressure while putting his shoes on. The patient was not able to walk. It was decided that we were going to do a severe Lapidus bunionectomy and to fix the second toe of the left foot.
    PROCEDURE IN DETAIL:
    The patient was placed in a supine position. It was decided to apply the thigh tourniquet on and to give a median block and digital block consisting of 2% lidocaine plain and 0.5% Marcaine plain. Once we did that, we decided to make our incision to locate the first medial cuneiform joint with the use of the mini C-arm. Prior to doing this, once the ankle tourniquet was applied, we decided to do a median block and digital block. After this was done, it was decided to prep and drape the foot in an aseptic manner. After doing this, the left lower extremity was exsanguinated for a couple of minutes and then ankle tourniquet was inflated. Attention was directed to make an incision over the area of the first metatarsal. We made sure we stayed medial to the extensor hallucis longus tendon and to resect anything in the area to get exposure to the first metatarsal cuneiform joint. With the use of the mini C-arm, we were able to locate our area inner most. Once we did this, we were able to move down to the base of the first metatarsal. Once we went down to the base of the first metatarsal and made our landmarks, we were able to remove any capsule and any soft tissue with complete meticulous dissection.
    Once we made it down to the area with meticulous dissection, we were able to expose the base of the first metatarsal and the head of the medial cuneiform. Once we had proper exposure with the use of the sagittal saw, we decided to take at least less than 0.5 mm or just the base of the first metatarsal. Once we made our cut into the base of the first metatarsal, there was some evidence of difficulty in removing the base of the first metatarsal as far as removing it with the use of the laminar spreader, but with the use of a rongeur and clamp, we were able to remove the base of the first metatarsal successfully.
    Our attention was then directed to the head of the medial cuneiform. Once we were at the head of medial cuneiform, we were able to remove the area of the first metatarsal cuneiform. Once we had complete resection, we were able to bring the two ends together. Once we brought the two ends together, it was noted that we were going to get some correct fixation and alignment, but the major problem was to get a proper plate and to make sure that we get proper fusion of the joint. Once we decided to use a 2.7 mm TMT fusion plate, we had some difficulties in making sure we had proper correction. All bleeders were ligated in a sterile fashion. It was copiously irrigated with normal saline.
    Because we could not get proper alignment with the 2.7 TMT fusion plate, we decided to use Synthes 2.7 mm cloverleaf fusion plate. We decided to bend the area in the middle to be able to obliquely center the fusion plate to the dorsal medial aspect of the first metatarsal, making sure that the middle was right at the joint and that the base of the first metatarsal and the head of the medial cuneiform would have a proper alignment.


    Through the drilling process o0f this fixation set with the 2.7 mm cortex screw, we overdrilled with a 2.0 drill bit/guide then we measured with a depth gauge. With the use of self-tapping screws, we were able to put in two 2.7mm x 20mm cortex screws, one 2.7mm x 30 mm screw. We also used two locking screws of 30 mm. We directly put two locking screws at the fixation site in place to bring the two ends together. After putting the plate on, we decided to also put a 2.7mm x 40 mm 1st met medial cuneiform joint to go across the joint. We decided to go with one screw obliquely across the joint to go dorsal, proximal, medial, to plantar, lateral, and distal across the first metatarsal medial cuneiform and to go toward the base of the second metatarsal at the medial cuneiform. We used a 40 mm 2.7 mm cortex screw to get proper fixation. Throughout the procedure, we used the mini C-arm. We checked for proper alignment and we were satisfied with the alignment.
    Once we did that and had the proper alignment, our attention was now directed into knocking off the bump of the medial eminence. We resected this and removed the medial eminence. It was decided to ligate all bleeders in a sterile fashion. We subcuticularly sutured the skin together. Once we subcuticularly sutured that, we did closure of the capsule with 2-0 Vicryl sutures. After reapproximating the capsule, we decided to do subcutaneous area. Once we did this, we were able to get proper skin closure.
    After doing the subcutaneous stitch, we decided to use 2-0 Prolene and do a horizontal mattress on the area of the skin. After doing a horizontal mattress, we noted that there was proper alignment. It was decided to take a picture with the mini C-arm. After taking the picture with the mini C-arm, we thought we were able to get proper alignment with no problem at all.
    Our attention was then directed to the head of the proximal phalanx. After making an incision over the head of the proximal phalanx, we did a transverse cut of the extensor tendon. After making a transverse cut in the extensor tendon, we were able to resect and remove the head of the proximal phalanx. After removing the head of the proximal phalanx, we noted that there was still some proper contraction. We later decided to go more distal to the second metatarsophalangeal joint and we made an incision. Now, we were able to do a tenotomy along the extensor digitorum longus tendon and then we were able to make a cut into the capsule to resect that.
    Once we did that, we noted that there was proper plantigrade pressure. We noted that there was evidence of some release of tissue. Once the release of tissue was done, we decided to approximate the extensor tendon with 3-0 Vicryl sutures and then we approximated the area with 3-0 Prolene. Once that was done, we noted that everything had been resected in the right place. There was definitely a decrease in the contraction of the second toe of the left foot.
    After doing that, we decided to give a postop injection consisting of 4 cc of Marcaine plain and 1 cc of Decadron into the area of the left foot. Once this was done, we decided to put a cast on the patient. We put a dry sterile dressing on the left foot. Once this was done, we deflated the ankle tourniquet. Once the ankle tourniquet was deflated, we noted that there was no evidence of any active bleeders. We put a dry sterile dressing on that area consisting of Adaptic, 4x4s and Webril, but we decided to put the patient in a nonweightbearing fiberglass cast.
    Last edited by codedog; 04-21-2011 at 12:38 PM.

  2. #2
    Location
    NEW ORLEANS
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    954
    Default
    Tough one

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