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Help w/op report-please

  1. #1
    Question Help w/op report-please
    Medical Coding Books
    Can anyone help me w/the following op report?

    Dx: Delayed union, nonunion of left hip (subtrochanteric fx)
    Procedure: Exchange of distal femoral locking screw bone grafting of left proximal femur.

    Pt had a distal femoral locking screw exposed through the skin, subcu and fascia. Preoperative antibiotics were given and the distal femoral screw then removed w/a screw-driver. using fluoroscopy on the lateral visualization and that second distal femoral screw placed, it measured to a 50 mm distal femoral area in the more metaphyseal area of the femur on the left side. AP and lateral visualization showed good placement of the screw w/appropriate locking. At that point the area was packed proximally. Localization performed w/fluoro scan and incision made through skin, subc, faxdia and using a Cobb elevator and self-retaining, the fracture area nonunion was exposed. There was some evidence of callous formation. No gross defect was noted. It was opted to proceed with this area. The area was scalloped w/a Cobb elevator and then roughened. Bone marrow injected directly into the fx area and then the area wide with infused graft. Bone marrow was then placed throughout the entire area held by the infused graft and then the hip closed...

    Any help would be greatly appreciated!

  2. Default
    You might want to check the description of procedure code 27472.

    Hope this helps.


  3. #3
    Thank you so much for your help!

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