I am relatively new to Foot surgery coding and my new MD presented me with the following description of services to code. Can you aide me some?
1. Crossover left third toe and dropped third toe, right.
2. Extensor digitorum longus release.
3. Medial collateral ligament release.
4. Dorsal capsulotomy MTP joint, left second with pinning.
5. Right syndactylism toes two and three.
Information from the Operative Report below:
Description of the Operation:
After successful induction, bilateral lower extremities were prepped and draped. The left was addressed first. Gravity exsanguination. Placed the tourniquet.
A transverse incision over the second PIP joint dissecting down reflecting soft tissues, removing distal proximal phalanx condyle, cut the subchondral bone off the middle phalanx. Now made a dorsal incision in the second web space. We dissected down, identified the long extensor, released that, then released the dorsal capsule on the medial collateral and this allowed the toe to sit down nicely, advanced the pin out the tip of the toe and retrograded into the proximal phalanx on the metatarsal head, holding the toe in a well positioned position, compressed the fusion site and repaired the extensor hood and then placed a Jurgan ball on the tip of the pin and Adaptic and Betadine.
Dressing applied after closure with Nylon and Marcaine infiltration, bulky dressing, Jurgan ball on the tip of the pin. We now had gravity exsanguinated the right foot as we let down the tourniquet on the left. We took a marker pen and drew out a diamond on the lateral aspect of the second toe and then brought it down and pushed it against the third where we had excised the skin, creating a diamond, essentially it was a triangle first, then we created a diamond and then we closed the skin approximating the second and third toes with Monopril, Adaptic, Betadine and compressive dressing applied.
The patient was discharged to the recovery room after deflating the tourniquet.
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