Would someone please review the attached OP note and tell me if they agree with my code selection? 28008, 28035, 64632
DESCRIPTION OF PROCEDURE: The patient was brought back to the operating room,
placed in supine position, and given general anesthesia by Dr. Once
that was done, the patient's foot was numbed with Marcaine with epinephrine in
and around the area of the tarsal tunnel and plantar fascia. Once that was
completed, the patient's foot was prepped and draped in normal sterile
fashion. Once prepping and draping was completed, a stockinette was cut.
Then an oblique incision was performed medial to the neurovascular structure
and lateral or anterior to the Achilles tendon. The incision was
approximately 5 cm in length. It was deepened down. Once the incision was
deepened down through the epidermal tissue, all subcutaneous tissue was
dissected down. Bleeders were ligated. The flexor retinaculum was identified
and was released. Once that was completed, Baxter's nerve was identified. It
was extremely superficial. It was actually sitting above the retinaculum, so
it was carefully dissected, making sure not to harm it. The retinaculum was
dissected, and the nerve was actually placed below the retinaculum in its
normal place. The nerve was released going to the posterior nerve down to the
heel. The abductor hallucis muscle belly was identified. Its fascial layers
were released. They were very taut. The plantar fascia was then identified,
and then one-half of the medial band of plantar fascia was released.
Dorsiflexion of the hallux showed good release. Thorough flush was performed.
No tourniquet was used. All bleeding was controlled via the surgery. Once
that was done, the patient then had a closure in layers, 3-0 Monocryl for the
subcutaneous tissue and then 3-0 nylon in a vertical mattress fashion for the
epidermal tissue. The patient was then given an injection of 6 mg of
dexamethasone in between the third and fourth interspace with a 25-gauge
needle with sterile technique. The patient was placed in a posterior splint
and educated on her condition. The patient will follow up in 1 week for
placement into a walking cast. No complications. No pertinent findings. The
patient tolerated the procedure well. The only pertinent finding was that the
patient's nerve was above the fascia rather than below.
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