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Thread: Op Note Coding Help

  1. #1

    Red face Op Note Coding Help

    AAPC: Back to School
    Please help with this op note:

    Op Note States:
    Athrotomy with implant fixation of 0.045 K wires to 2md MPJ of the right foot:[/B] Attention was directed over the dorsal aspect of the right mid foot 2nd ray where approximately 2cm linear incision was made in the area of the metatarsal. Dissection was carried down to the level of the superficial fascia, taking care to preserve or retract all vital neurovascular structures. Dissection was then carried to the level of the extensor apparatus which was clearly identiied and transected.

    Capsulotomy was performed at this time and based on the fluoroscopy evaluation it appears that the head of the 2 metatarsal is highly plantar flexed. Utilizing pair of Holmen's the 2nd metatarsal was brought to the operative field and appears to be within normal limits. The contracture appears to be the plantar plate which was then freed. Based ont he overall correction of the functional correction, the intra operative decision was made not only to free the joint but also place an implant fixation across the joint for proper alignment and positioning in conjunction with the repair of the tendon.

    After copious irrigation the metatarsal was brought from the plantar flexion position and lifted up and was the fixated with a 0.045 K wire which was placed across the MPJ for proper alignment. After copious irrigation once again, the intra operation decision was made to repair the tendon and capsule structure utilizing 3-0 Vicryl and 4-0 Nylon respectively.

    I need help with the above note. I cannot find a code that matches what the physician has done. For any help I will be truly thankful.

  2. #2
    Join Date
    Apr 2007
    San Antonio, TX


    what was the diagnosis for this procedure? hammer toe or dislocation? try looking at 28270 Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure)
    this may be as close as you can get.
    Revenue Cycle Supervisor

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