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Help w/op note-Please

  1. #1
    Default Help w/op note-Please
    Medical Coding Books
    Post op dx: stress fracture of the rt femur.

    Surgical procedure: Cortical strut bone grafting of the femur for biological plating.

    Indications: 66 yr old female w/hx of rt femoral stress fx. We discussed the pros and cons of multiple treatments and was opted for biological plating w/2 anterolateral strut grafts and cable grafting.

    Procedure: ...She had a lateral approach made after being placed in the lateral decubitus position, care taken to pad the perineum, ulna and chest appropriately. She had a lateral approach to the thigh made after visualization and localization on fluoroscan through skin and subcutaneous fascia. The vastus lateralis was dissected leaving a little cuff of tissue in the posterior aspect of the vastus lateralis, coagulated perforators as we encountered them. The incision was made the length of the strut graft and at that point on visualization we could actually palpate and see the stress fx. The entire femur was then cut in half and then contoured and one plate was placed anteriorly and on plate was placed laterally. For cerclage a cable was placed and tightened to 30 pounds in sequence. The patient had coagulation and hemostasis obtained with Aqua Mephyton and Bovie cautery. The vastus lateralis was closed w/2-0 running interlocking Vicryl stitches, TFL closed w/0 Vicryl running interlocking stitches, 2-0 vicryl used to close subcutaneous, skin was closed with the running subcuticular stitch and Steri-Strips.

    Can anyone point me in the right directions with this? Your help will be greatly appreciated!
    Thanks,
    Cathy

  2. #2
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    27507 w/733.15

  3. #3
    Default
    Mary,
    Thank you! That was my first thought but started to second guess myself. I hate when I do that! lol

  4. #4
    Location
    Albany, New York
    Posts
    456
    Default
    I think dx code would be 733.97
    Karen Maloney, CPC
    Data Quality Specialist

  5. #5
    Location
    Albany, New York
    Posts
    456
    Default
    Maybe I am missing something.......

    I don't see anything in the description of CPT 27507 that refers
    to bone grafting (??)
    Karen Maloney, CPC
    Data Quality Specialist

  6. #6
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    forgot about the new dx codes for stress fractures, you are right 733.97 is the correct dx.
    thanks Kathy!!

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