Our Dr performed the following surgery and I'm having difficulty coming up with coding. Has anyone had to bill this out before and what coding did you use? I'm leaning towards unlisted.
PREOP DIAGNOSIS: RIGHT FOOT CHRONIC RECALCITRANT PLANTAR FASCIITIS
POSTOP DIAGNOSIS: SAME
PROCEDURE: RIGHT PLANTAR FASCIA TENOTOMY WITH TOPAZ RADIOFREQUENCY WAND
ANESTHESIA: GENERAL ET
INTRODUCTION: Routine preop evaluation revealed no medical contraindication to surgery. The patient and family were consulted at length regarding the relative risks, benefits, and alternatives of the above elected procedure. They understood these risks to include but not be limited to infection, sepsis, osteomyelitis, DVT, PE, stroke, MI, death, nerve or blood vessel damage, RSD, persistent pain, stiffness, requirement for future operative intervention, among others. Understanding all the above risks and that no guarantees were made nor implied, the patient freely consented to proceed.
OPERATIVE PROCEDURE: Patient was taken to the operating room on 5/2/12 where she was transferred to the OR table and placed in the supine position without event. She was induced under general anesthesia and intubated via the ET route. Prior to initiation of the operative procedure, the American Academy of Orthopedic Surgeonsâ€™ timeout protocol was instituted. This assured the patientâ€™s name, the correct extremity, the correct side, the patientâ€™s allergies, their preoperative medications and antibiotics. Following completion of the appropriate timeout and verification of all the above, we proceeded with the operative procedure. The patient received 1 gram Ancef as antibiotic preop prophylaxis in preoperative holding. A tourniquet was placed about the right proximal thigh. All bony prominences were carefully and thoroughly padded. The head and neck were secured in neutral position. The RLE was prepped and draped in the usual sterile fashion. The limb was exsanguinated with a sterile Esmarch bandage. The tourniquet was inflated to 250 mmâ€™s mercury.
A 2.0 cm longitudinal skin incision was made on the medial plantar aspect of the heel just distal to the plantar fascia origin. Dissection was carried down to the plantar fascia. Visualization of the medial half of the plantar fascia was obtained. Utilizing the Topaz RF wand, 15 perforations were created into the plantar fascia, pie-crusting the plantar fascia in the desired manner. The wound was then irrigated with normal saline and closed with 3-0 Monocryl subcuticular sutures, followed by 3-0 nylon vertical mattress sutures. A bulky compressive dressing was applied with a postop shoe.
The patient was extubated in the OR and returned to recovery in good condition. There were no noted complications. Sponge, needle and instrument counts were correct at the end of the operative procedure. EBL was minimal. Tourniquet time was 10 minutes.
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