Omy13
Contributor
Hi -
I submitted a claim with CPT 24586 with ICD 10 -S42.441A, S53.441A and the claim was denied for the diagnosis. Please see Op Report below. If any one can help.
PRELIMINARY DIAGNOSIS:
1. Right elbow medial epicondyle avulsion fracture
POSTOPERATIVE DIAGNOSIS:
1. Same
NAME OF OPERATION:
1. Right elbow arthrotomy open reduction internal fixation medial epicondyle
ANESTHESIA:
periph nerve block
ANESTHESIOLOGIST:
Anesthesiologist: Yadeau, Jacques T, MD
CRNA: Ward, Dakota, CRNA
Anesthesia Fellow: Anis, Monica, MD
PROCEDURE START:
1:42 PM
PROCEDURE END:
2:56 PM
SPECIMENS:
* No specimens in log *
ESTIMATED BLOOD LOSS:
Minimal
INTRAVENOUS FLUIDS:
1,000 ML OF RINGER'S LACTATE.
COMPLICATIONS:
* No complications entered in OR log *
TOURNIQUET TIME:
Total Tourniquet Time Documented:
Upper Arm (Right) - 50 minutes
Total: Upper Arm (Right) - 50 minutes
IMPLANTS:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No. Used Action
SCREW BONE 4MM 5MM 1.35MM 30MMLCP SS .5 THRD SM HEX RVRS - SN/A - LOG1757192 SCREW BONE 4MM 5MM 1.35MM 30MMLCP SS .5 THRD SM HEX RVRS N/A Depuy Synthes - A Johnson and Jo N/A Right 1 Implanted
OPERATIVE INDICATIONS:
The above patient is well-known to me. He is a baseball player who sustained an avulsion fracture of the medial epicondyle during pitching event. There is displacement of the fracture and he is indicated for open reduction internal fixation.
PROCEDURE:
After successful induction of anesthesia the patient's right upper extremities prepped and draped in normal sterile fashion the operating room table with a hand table. Surgical and marks were identified and the arm was exsanguinated with an Esmarch.
Curvilinear incision over the medial epicondyle was opened. Fluoroscopic images in both AP and lateral and oblique planes were obtained during reduction of the medial epicondyle fracture. The pointed reduction clamp was placed medially and laterally in the lateral epicondyle.
Guidewire was placed up the medial calcar of the humerus and a 30 mm partially-threaded cancellous screw was placed up the medial epicondyle into proximal humerus bridging the fracture epicondyle.
Guidewire was removed and placement of the screw was confirmed on AP lateral and oblique imaging.
Tourniquet was deflated and wound was closed in a layered fashion the patient was placed in a posterior splint. He was discharged home same day of surgery.
Please note Madeline Kratz, PA was the primary assistant and was present for the entire procedure from beginning to end; her experience and knowledge as surgical assistant was medically necessary in order to perform this procedure to assist with position, performance of the procedure including graft preparation, and closure
The patient was transferred in stable condition to recovery unit.
I submitted a claim with CPT 24586 with ICD 10 -S42.441A, S53.441A and the claim was denied for the diagnosis. Please see Op Report below. If any one can help.
PRELIMINARY DIAGNOSIS:
1. Right elbow medial epicondyle avulsion fracture
POSTOPERATIVE DIAGNOSIS:
1. Same
NAME OF OPERATION:
1. Right elbow arthrotomy open reduction internal fixation medial epicondyle
ANESTHESIA:
periph nerve block
ANESTHESIOLOGIST:
Anesthesiologist: Yadeau, Jacques T, MD
CRNA: Ward, Dakota, CRNA
Anesthesia Fellow: Anis, Monica, MD
PROCEDURE START:
1:42 PM
PROCEDURE END:
2:56 PM
SPECIMENS:
* No specimens in log *
ESTIMATED BLOOD LOSS:
Minimal
INTRAVENOUS FLUIDS:
1,000 ML OF RINGER'S LACTATE.
COMPLICATIONS:
* No complications entered in OR log *
TOURNIQUET TIME:
Total Tourniquet Time Documented:
Upper Arm (Right) - 50 minutes
Total: Upper Arm (Right) - 50 minutes
IMPLANTS:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No. Used Action
SCREW BONE 4MM 5MM 1.35MM 30MMLCP SS .5 THRD SM HEX RVRS - SN/A - LOG1757192 SCREW BONE 4MM 5MM 1.35MM 30MMLCP SS .5 THRD SM HEX RVRS N/A Depuy Synthes - A Johnson and Jo N/A Right 1 Implanted
OPERATIVE INDICATIONS:
The above patient is well-known to me. He is a baseball player who sustained an avulsion fracture of the medial epicondyle during pitching event. There is displacement of the fracture and he is indicated for open reduction internal fixation.
PROCEDURE:
After successful induction of anesthesia the patient's right upper extremities prepped and draped in normal sterile fashion the operating room table with a hand table. Surgical and marks were identified and the arm was exsanguinated with an Esmarch.
Curvilinear incision over the medial epicondyle was opened. Fluoroscopic images in both AP and lateral and oblique planes were obtained during reduction of the medial epicondyle fracture. The pointed reduction clamp was placed medially and laterally in the lateral epicondyle.
Guidewire was placed up the medial calcar of the humerus and a 30 mm partially-threaded cancellous screw was placed up the medial epicondyle into proximal humerus bridging the fracture epicondyle.
Guidewire was removed and placement of the screw was confirmed on AP lateral and oblique imaging.
Tourniquet was deflated and wound was closed in a layered fashion the patient was placed in a posterior splint. He was discharged home same day of surgery.
Please note Madeline Kratz, PA was the primary assistant and was present for the entire procedure from beginning to end; her experience and knowledge as surgical assistant was medically necessary in order to perform this procedure to assist with position, performance of the procedure including graft preparation, and closure
The patient was transferred in stable condition to recovery unit.