AAPC - Chapter 8 Practical Applications--Alison_Erving

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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.

What are the CPT® and ICD-10-CM codes reported?

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Terms in this set (10)

23616-LT
S42.202A

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.

What are the CPT® and ICD-10-CM codes reported?

22514
M48.56XA

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.

What are the CPT® and ICD-10-CM codes reported?

20690-LT
25605-51-LT
S52.532A

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.

What are the CPT® and ICD-10-CM codes reported?

24565-RT
24605-51-RT
S42.441A
S53.104A

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.

What are the CPT® and ICD-10-CM codes reported?

26055-F7
20610-51-LT
M65.331
M75.52