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CASE 1
Operative Report
PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture.
POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.)
OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.)
ANESTHESIA: General.(General anesthesia is used.)
IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introduced into the joint.)
INDICATIONS: The patient is a 66 year-old female who sustained a traumatic severe comminuted proximal humerus fracture. (This is confirmation of the diagnosis. The proximal end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were discussed. She stated that she understood and desired to proceed.
DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where she was prepped and draped in the usual sterile fashion in beach chair position after administering general anesthesia. Standard deltopectoral approach was used.(The approach is documented within the body of the operative report.) The cephalic vein was taken laterally with the deltoid. Dissection was carried out down to the fracture site and the fracture was identified. The fragments were mobilized and the humeral head fragments were removed. Once this was done, the stem was prepared up to a size 10.(This further explains the comminuted fracture.) A trial reduction was carried out with the DePuy trial stem and implant head.(Placement of the prosthesis is described.) This gave good range of motion with good stability. Sutures down to and through the shaft were placed in key positions for closure of the tuberosities. The shaft was prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and then reduced. A bone graft was placed around the area where the tuberosities were being brought down.(Bone grafts are common in prosthetic placement. A matrix is provided where new bone can grow and further stabilize the prosthesis. These are not reported separately.) The tuberosities were tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with vicryl over a drain and staples in the epidermis. A sterile dressing and sling were applied. The patient was taken to recovery in stable condition. There were no immediate complications.
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CASE 2
PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.
POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.)
NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.)
FINDINGS PREOPERATIVELY:
She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. She initially had very good results, but then developed back pain once again. The repeat MRI two weeks later showed that she had fresh high intensity signal changes in the body of L2 and some scalloping of the superior end plate, consistent with a compression fracture at L2.(The diagnosis is confirmed in the body of the report.) After some preoperative discussions and patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she did not improve. At surgery, L2 had some scalloping of the superior end plate. Most of the softness was in the back part of the vertebral body.
PROCEDURE:
The patient was taken to the operating room and placed under general endotracheal anesthesia(The type of anesthesia utilized is documented within the report. General anesthesia was used.) in a supine position. She was then placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. Using biplane image intensifiers, the skin incision sites were marked. 0.5% Marcaine with epinephrine was injected. Initially on the left side. A Kyphon trocar was passed down to the superior lateral edge of the pedicle, through the pedicle, and into the vertebral body in the usual fashion.(This describes the approach to the defect. It is percutaneous using trocars.) The drill was placed into the vertebral body followed by the Kyphon bone tamp. In a similar fashion, the same thing was done on the other side. Balloons were inflated uneventfully. The balloons were then deflated and removed, and the cement (when it was in the doughy state) was injected into the two sides in the usual fashion.(This describes how the area is enlarged and the cement is placed in a kyphoplasty procedure.) This was done carefully and sequentially to make sure there were no cement extrusions, which after inspection, there were none. There was a good fill to the vertebral body edges, up towards the superior end plate, and across the midline. The bone filling devices were removed, and the trocars were removed, Pressure was applied after which the skin was sutured with 4-0 nylon. Sand-Aids were applied and she was taken to recovery in stable condition.
COMPLICATIONS: There were no complications.
BLOOD LOSS: Minimal blood loss.
COUNTS: Sponge and needle counts were correct.
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CASE 3
PREOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist.
POSTOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist.(The postoperative diagnosis is used for coding.)
PROCEDURE: Application of a uniplane fixation and closed reduction of left distal radial fracture under fluoroscopy.(This is the working procedure until the report is read.)
ANESTHESIA: General endotracheal.(General anesthesia used.)
DESCRIPTION OF THE PROCEDURE:
After induction of adequate general anesthesia, the patient's left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 ml of mercury. We placed two half pins distally over the dorsoradial aspect of the second metacarpal. The first was placed in freehand technique making an incision, spreading with a hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius.(The external fixation component of the procedure is further described.) We connected these two pins with clamps, and then under C-arm control, we reduced the fracture.(This supports the closed reduction under fluoroscopy.) All pins are now attached to the external fixation. This fracture at both the dorsal and volar comminution(The comminuted aspect of the diagnosis is confirmed.) and intraarticular fractures was significantly shortened and telescoped. We obtained the best reduction possible, and tightened down the clamps to the bars. The pin tracks were dressed with Xeroform and 2 x 2 gauze, and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications.
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CASE 4
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Dislocation of right elbow.
POSTOPERATIVE DIAGNOSIS: Dislocation of right elbow with medial epicondyle fracture.(The postoperative diagnosis is used for coding.)
OPERATIVE PROCEDURE: Closed reduction of elbow dislocation with a closed reduction of medial epicondyle fracture.(This is the working procedure until the report is read.)
ANESTHESIA: General.(General anesthesia used.)
INDICATIONS: This is a 12 year-old male who had an injury, sustaining a dislocation of his right elbow and medial epicondyle fracture.(The diagnosis is confirmed in the body of the report.) The risks and benefits of surgical treatment were discussed with the family, who stated they understood and wanted to proceed.
DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where general anesthesia was induced. Once he was under adequate anesthesia, the reduction maneuver was performed.(There is no indication the skin was cut, which reflects a closed method of reduction.) The elbow was reduced and was stable. Through full range of motion there was noted to be a slight crepitus on the medial elbow and some mobility was felt in the medial epicondyle. Examination under C-arm imagery(C-arm imagery indicates fluoroscopy was used.) revealed a concentric reduction of the elbow, but with mildly unstable medial epicondyle fracture. When the elbow was held in the appropriate position, the medial epicondyle was well reduced in an acceptable position.(Manipulation of the medial epicondyle supports closed reduction of the fracture.) It was elected to treat this non-surgically. A long arm splint was applied.(This is showing the fracture was reduced and set.) The patient was awakened from anesthesia and taken to recovery in stable condition with no immediate complications.
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CASE 5
PREOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left shoulder impingement/subacromial bursitis.
POSTOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left shoulder impingement/subacromial bursitis.(The postoperative diagnosis is used for coding.)
PROCEDURES:
Right long finger trigger release. Injection of the left shoulder with Xylocaine, Marcaine and Celestone via anterior subacromial approach.
ANESTHESIA: General.(General anesthesia used.)
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
REPLACEMENT: Crystalloids.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where he was given general anesthesia. The right upper extremity was prepped and draped in the usual sterile fashion. While draping, the left shoulder was prepped with Betadine; and through an anterior subacromial approach, the left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine.(Documentation confirms the left shoulder injection.) The patient tolerated the procedure well.
Meanwhile, the right hand had been prepped and draped. It was exsanguinated with an Esmarch bandage, and the tourniquet inflated to 250 mm. I made an incision over the A1 pulley(The A1 pulley is a flexor tendon pulley.) in the distal transverse palmar crease, about an inch in length. This was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. Care was taken to avoid injury to the neurovascular bundle.(The release of the nerve is described, which is a trigger finger release.) The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. A clean dressing was applied. The patient was awakened and taken to the recovery room in stable condition.
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CASE 6
PREOPERATIVE DIAGNOSIS: Painful hardware, left foot.
POSTOPERATIVE DIAGNOSIS: Painful hardware, left foot.
PROCEDURE PERFORMED: Removal of hardware, left foot
ANESTHESIA: Sedation and local
DRAIN: None.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR PROCEDURE:
The patient had his status post metatarsal fracture, treated with internal fiixation. Patient has suffered pain due to hardware for the past six months. Patient's pain has been unresponsive to conservative treatment. We discussed the above-mentioned surgery, along with the potential risks and complications, and the patient understood and wished to proceed.
DESCRIPTION OF PROCEDURE:
With the patient supine on the operating table after the successful induction of anesthesia, the left foot was prepped and draped in the usual sterile fashion. In the area of the screw heads, 0.5% Marcaine was injected, both on the lateral side of the foot and the dorsal midfoot, administering about 5 ml in each area. Small 0.5 cm incisions through the skin were made and blunt dissection was carried down to the screw heads. The screws were removed with the screwdrivers. The incisions were irrigated and closed with simple 4-0 nylon sutures. A sterile compression dressing was applied. The patient was taken to the recovery room in satisfactory condition.
MATERIAL SENT TO LABORATORY: None.
COMPLICATIONS: None.
CONDITION ON DISCHARGE: Satisfactory.
DISCHARGE DIAGNOSIS: Painful hardware, left foot.
DISCHARGE PLAN:
Discharge instructions were discussed with the patient. A copy of the instructions was given to the patient and a copy retained for the medical record. The following items were discussed: diet, activity, wound care medications if applicable, when to call the physician, and follow-up care.
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CASE 7
Procedure performed in office.
PREOPERATIVE DIAGNOSIS: Right-sided thoracic pain.
POSTOPERATIVE DIAGNOSIS: Right-sided thoracic pain.
OPERATION: Trigger point injection into the right-sided thoracic spine musculature, into the rhomboid major, rhomboid minor, and levator scapular muscles.
PROCEDURE:
The patient was seated on the bed. He has metastatic right lung cancer. The risks of the procedure, including bleeding, infection, nerve damage, and no guarantee of symptom relief were explained. The patient agreed to the procedure and the informed consent was signed.
I palpated for areas of maximal tenderness. Five points were marked over the right-sided thoracic paraspinal musculature. I then cleaned off his back with chlorhexidine x2. Then I used a 25 gauge 1.5-inch needle on a 10 cc controlled syringe with 40 mg/ml Depo-Medrol. After negative aspiration, 1 cc was injected into each point. A total of four points were injected. A total of 4 cc (160mg) was used. The patient tolerated the procedure well. Band-Aids were not placed. The patient was not bleeding.
We are refilling the patient's pain medication. He is seeing an oncologist and gets Percocet 7.5/500. He takes four a day, providing him with pain relief. We will dispense to him today a three-week supply. We are going to dispense #84. He is to return to the office in two weeks, at that time we will get a urine specimen for follow-up. Emphasized to the patient, once again, that he had to bring his pills to every appointment according to the opioid contract.
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CASE 8
OPERATIVE REPORT
Preoperative Diagnosis: Plantar fasciitis, left
Postoperative Diagnosis: Same as preoperative diagnosis.
Procedures: Plantar fasciotomy, left heel.
For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating the patient understands the procedure and its possible complications.
This 61 year-old male was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion. Attention was directed to the left heel where, utilizing a 61 blade, a stab incision was made, taking care to identify and retract all vital structures. The incision was deepened to the medial band insertion of the fascia. The fascia was then incised and avulsed from the calcaneus. The surgical site was flushed with saline. Next, 1 cc of Depo-Medrol was injected in the operative site. The site was dressed with a light compressive dressing. Excellent capillary refill to all of the digits was observed without excessive bleeding noted.
Hemostasis: none
Estimated Blood Loss: minimal
Injectables: Agent used for local anesthesia was 5.0 cc Marcaine 0.5% with epinephrine.
Pathology: No specimen sent.
Dressings: Applied Bacitracin ointment. Site was dressed with a light compressive dressing.
Condition: Patient tolerated the procedure and anesthesia well. Vital signs were stable. Vascular status was intact to all digits. Patient recovered in the operating room.
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CASE 9
PREOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture.
POSTOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture.
OPERATION PERFORMED: Open Left Achilles' tendon repair.
ANESTHESIA: General anesthesia
INDICATIONS: The patient is a 25 year-old male who was playing basketball when he was hit by another player and felt a pop in the back of his ankle approximately two months ago. Examination reveals a positive Thompson test, but no plantar flexion on squeezing the calf. There is a palpable defect in the Achilles' tendon. There is swelling in this region and neurovascular examination is intact. Given these clinical findings, the patient is taken to the operating room for the aforementioned procedure.
DESCRIPTION OF PROCEDURE: Following induction of general anesthesia the patient was placed prone on the operating table and all bony prominences were well-padded. The patient received a 1g dose of Ancef. Under tourniquet control of 250 mmHg, a longitudinal incision was made followed by opening up the paratenon of the Achilles' tendon. An obvious rupture was noted. The hematoma was evacuated and the ends were then debrided with a Metzenbaum scissors. A No. 2 FiberWire® was placed in a Bunnell-type fashion in both the proximal and distal portions of the Achilles' tendon. A No. 2 Orthocord was then used and placed in a running fashion along the proximal and distal portions of the Achilles' tendon. A total of four sutures were used. These were then tied together to re-approximate the tendon with no significant tension on the repair.
A secure repair was noted. The ends of the repair were further augmented with a 2-0 Vicryl suture. The wound was thoroughly irrigated with antibiotic irrigation solution. The fascial plane was closed with a 2-0 Vicryl suture, followed by closing the skin with a 2-0 in subcuticular fashion. Approximately 10 cc of 0.5% Marcaine was injected for postoperative pain control. A routine dressing was applied to the extremity, and it was placed into a short leg cast with the foot slightly plantar-flexed. The anterior aspect of the cast was then univalved. The tourniquet was deflated for a total tourniquet time of 42 minutes.
The patient was awakened in the operating room breathing spontaneously and taken to the recovery room in stable condition.
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CASE 10
PREOPERATIVE DIAGNOSIS: Right ankle triplane fracture
POSTOPERATIVE DIAGNOSIS: Right ankle triplane fracture
PROCEDURE: Open reduction and internal fixation (ORIF), right ankle triplane fracture
ANESTHESIA: General endotracheal
COMPLICATIONS: None
SPECIMEN: None
IMPLANT USED: Synthes 4.0 mm cannulated screws
INDICATIONS FOR PROCEDURE:
The patient is a pleasant 15 year-old male who fell and sustained a right ankle triplane fracture. This was confirmed on both X-ray and CT scan. The indications for ORIF were explained to the patient, as well as the possible risks and complications, which include infection, bleeding, stiffness, hardware pain, the need for hardware removal, and there is no guarantee of a functional ambulatory result. The patient and family understood and wished to proceed.
PROCEDURE IN DETAIL:
The patient was brought back to the operating room and placed on an operating table, given a general anesthetic without any complications, and given preoperative antibiotics per usual routine. He had the right lower extremity prepped and draped in the usual sterile fashion with alcohol prep followed by routine Betadine prep.
Under X-ray guidance, a pointed reduction clamp was placed from the anterolateral corner of the distal tibia to the medial side, and I reduced the triplane fracture. It was confirmed on both AP and lateral X-ray images the gap was reduced. The patient then had guidewires taken from the Synthes 4.0 mm cannulated screw set. One was placed medially along the epiphysis on the anterior half of the epiphysis and parallel to the joint to catch the lateral aspect of the epiphysis. One screw was placed above the physis from anterior to posterior to capture that spike. Once the wires were in the appropriate position, the length was measured and partially threaded 4.0 mm cancellous screws were selected so all threads were across the fracture site. The appropriate length screws were placed, confirmed by an X-ray to be in good position. The fracture was anatomically reduced, and the ankle joint was anatomic. The patient had wounds copiously irrigated. Closure was done with interrupted horizontal mattress 3-0 nylon suture. The patient had a sterile compressive dressing applied, was placed into a three-sided posterior mold splint, was extubated, and brought to the recovery room in stable condition. There were no complications. There were no specimens. Sponge and needle counts were equal at the end of the case.
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This 36 year-old female presents with an avulsed anterior cruciate ligament off the femoral condyle with a complete white on white horizontal cleavage tear of the posterior horn of the medial meniscus, causing instability. A general endotracheal anesthesia was performed, and the patient was placed supine on the operating table. The right lower extremity was prepped with Betadine and draped free. Standard arthroscopic portals were created, and the knee was systematically examined and probed. The posterior horn of the medial meniscus was noted to be buckled and frayed. This area was carefully probed and found to be irreparable. It was decided that our best option was to proceed with a limited partial meniscectomy, with the goal being to leave as much viable meniscal tissue as possible. Therefore, a medial infrapatellar portal was developed with a longitudinal stab wound. A series of straight-angled and curved basket punches was used to perform a saucerization of the damaged portion of the meniscus, leaving the intact portion of the medial meniscus in place. Debris was meticulously removed with the 4.0 meniscal cutter. Approximately 50% of the medial meniscus remained. Next, our attention was turned to the ACL repair. Through a 5 cm longitudinal anterior incision, a central one-third tendon bone was harvested. A 10 mm graft was taken and bone plug sculpted. Anterolateral notchplasty was done with a curette and polished with the burr. All debris was removed and instruments were used to ensure proper isometry. The graft was tightened in extension about 2.5 mm and actually lengthened in flexion, and this was considered acceptable. Endoscopic guides were used to create the tibial and femoral tunnels, and the edges were rasped smooth. Using a percutaneous guide pin, the graft was placed retrograde to the knee and secured proximally with an 8 x 25 mm interference screw. The knee was put through range of motion, and with the leg in 30 degrees of flexion with the posterior drawer applied to the proximal tibia; an 8 x 20 mm interference screw was used to secure the bone plug distally. The graft was tight, isometric and without adverse features. The wound was copiously irrigated with Kantrex1. Cancellous bone fragments from bone plugs were used to graft the donor site defect in the patella. The paratenon was closed over this to house the graft with a running #1 Vicryl. The edge of the distal bone plug was beveled with the rongeur. The subcutaneous tissue was closed with triple-0 Vicryl. Skin was closed with double-0 Prolene in a subcuticular fashion. Steri-Strips, sterile dressing, cryo cuff and hinged knee brace were applied. The patient was awakened and taken to the recovery room in satisfactory condition. What CPT® codes are reported?
A) 29888-RT, 29881-51-RT
B) 29889-RT, 29880-51-RT
C) 29888 -RT, 29882-51-RT
D) 29888-RT, 29880-51-RT