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Please help with short op-note

  1. Question Please help with short op-note
    Medical Coding Books
    Please help me code this?

    The leg was then elevated for greater than 5 minutes and the tourniquet was elevated to 300 mmHg. Under fluoroscopy, the distal aspect of the fibula was demarcated as well as the area of the ankle joint. A hockey-stick type of incision was made in the anterior aspect of the fibula in the area of the lateral ankle gutter. This was taken down through subcutaneous tissue with bleeders clamped and bovied in the usual way. The incision was taken down to the anterior aspect of the fibula where the marked prominence of bone was clearly seen. Careful dissection, blunt and sharp, was then performed and the area was clearly identified. Interestingly that this bone area was between the talofibular ligament and the tib-fib ligament. It appeared to be having a cartilage cap of a very thin layer and; therefore, appeared to be more of an osteochondroma that was probably had occurred secondary to her old growth plate in this area. Using an osteotome, this was removed and sent to pathology. At its just distal tip, small ganglion cyst arose from the lateral gutter of the ankle joint and this was then excised and sent to pathology as well. The anterior talofibular ligament was clearly identified and noted to be totally intact. The area underneath the tib-fib ligament in the ankle joint itself in the lateral gutter was examined and felt to be smooth without any irregularities. Therefore, the wound was then irrigated out well. Bone wax was applied to the exposed area bone marrow where the osteotomy and excision of the osteochondroma were performed. The wound was then closed in layers.

  2. #2
    Piedmont Area Coders, VA
    How about 213.7, 27635 for the osteochondroma, (verify w path it IS an osteochondroma for 213.7)
    and 727.41, 27630 for your ankle ganglion.



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