# Stuck on hands ! Please help



## Justarose (Jun 15, 2009)

Okay ...I am a few hours into this ! and I need help please ...

POSTOPERATIVE DIAGNOSIS:	Rheumatoid arthritis with severe deformity left wrist, metacarpophalangeal joints and proximal interphalangeal joints, two through five. 

PROCEDURES PERFORMED:	
1.   Fusion left wrist with intramedullary nail.
2.	Metacarpophalangeal arthroplasty left index, middle, ring, and small; DePuy #30, index, #30, middle; #10, ring; and #10, small.
3.	Proximal interphalangeal fusion left index and middle finger.
4.	Pinning of supple swan-neck deformities left fourth and fifth fingers.
5.	Excision of posterior interosseous nerve left wrist.


Here is what I have so far : 
                                         #1 25800 
                                         #2 26531 x 4 
                                         #3 26860 x2
                                         #4  HELP 
                                         #5 64772 

Here are the notes : 
  The PIP joints of the index and middle fingers were addressed first through curvilinear incisions.  The extensor tendons were identified and split longitudinally.  The remaining cartilage, minimal as it was, was removed from the PIP of the index and middle fingers.  We then hyperflexed the joint and removed the volar plate.  This allowed us reduction with a 30-degree flexion of the PIP joint.  A 0.035 K-wire was placed across the proximal aspect of the middle phalanx; and then, a 28-gauge wire placed through this hole.  
Two 0.035 K-wires were placed in an antegrade fashion across the PIP joint and then the tension-band wire construct completed to place 30 degrees of flexion at the index and middle finger PIP joints.  The wires were cut and bent and noted to be in good position clinically radiographically.  Then, the wounds were irrigated.  The extensor mechanism was repaired with a 3-0 Ethibond.  The skin was then closed with a 5-0 Prolene. 

 Attention was directed towards the MP joints.  Longitudinal incisions were then made in the dorsal second and fourth web spaces.  Cutaneous flaps were elevated.  The extensor tendons were subluxated into the ulnar valley after release of the ulnar sagittal band to the index, middle, ring, and small fingers.  We were able to elevate the capsule to each digit and then performed a distal resection of the metacarpal head.  This bone was used for later bone grafting at the radius.  I resected the level of the metacarpal at the level of the neck just at the collateral ligament insertion.  Once all metacarpals were resected, the hand broached proximal and then distal on the index and middle up to a 30 and appeared quite stable and ring and small up to a 10.  We then trialed implants.  The implants appeared to be quite stable and supple.  She did not require any volar plate arthroplasty or release palmarly and had very good motion.  The wounds were irrigated.  

At this point, a longitudinal incision was made over the dorsal wrist.  The EPL was transposed and the capsule elevated.  Diffuse synovitis was removed from the radiocarpal joint.  We removed the cartilage from the scaphoid, capitate, hamate, triquetrum, and lunate.  The bones themselves were quite osteoporotic; and after removal of bone and cartilage, these were used for later bone graft.  We then placed an awl through the third metacarpal neck across the radius.  We denuded the cartilage from the distal radius and then placed an intramedullary guide at the level of the metadiaphyseal flare of the third metacarpal, stabilizing the radius nicely.  This 3/16 x 16 pin was driven nicely.  This stabilized the carpus nicely and radiographically was noted to be in good position.  All wounds were irrigated.  The capsule was repaired with a 3-0 Ethibond at the wrist including ECRL for capsule repair.  The skin was then closed with a 4-0 Prolene.  

The posterior interosseous nerve was excised at the wrist prior to the wrist closure.  At this point, the implants were placed in the index, middle, ring, and small fingers using the DePuy silicone NeuFlex implants.  The capsule was repaired with 3-0 Ethibond.  The radial sagittal band was imbricated with a 3-0 Ethibond, aligning the extensor tendons; and then, the skin was closed with a 5-0 Prolene.  

A dry dressing was applied after pinning the PIP of the fourth and the fifth in 30 degrees of flexion.  The pins will be left for two to three weeks, as she has a supple swan-neck deformity.  Once the splint was applied, the tourniquet was released.  The fingers pinked up nicely.  The patient was transferred to the recovery room in stable condition. 

I could be "off" on everything else ...please feel free to offer your expertise ... I am lacking ..
   Do I need to use modifiers anywhere ... I didn't think so ( ? ) 
Thanks so much !


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## mitchellde (Jun 15, 2009)

put LT modifier on wrist, then you will need finger modifiers on your other procedures, do not use units use modifers, the pinning of the PIP on the 4th and 5th fingers I would use the fusion code 26860 again with finger modifiers and the 64772 is for a spinal nerve so I would not use it, I come back to 2 approaches on that, either do not code it as it is inclusive to the 25800 or use unlisted 64999.  Let me know if you need help with the modifiers.
Debra Mitchell MSPH, CPC-H


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## Justarose (Jun 16, 2009)

Thanks Debra ! I'm okay with the modifiers ... I was so stuck on the pinning of the PIP 4th and 5th ...so now its a "da" moment ... as for the PIN ...wow...have I been off on that ? I thought it was a good code even though it is spinal since the nerve is connected ?? 



thanks for your help !


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## mitchellde (Jun 16, 2009)

I could see the logic you were going for however the procedure description shows this to be via a spine approach.  Do you have a good procedure description book?  they are well worth the price.  Anyway as to the pin, from reading the op note it looked like a type of fusion was the goal so that is why I suggested that.


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## Justarose (Jun 16, 2009)

Debra I am not provided with any books which is very difficult for me ... I really loved having them around in my previous job and there are so many and if I have to lay out the money I need the right one ...can you reccommend a good one ? I was thinking about Netters Atlas ...what are your thoughts - if I have to spend the money I want it to be the right book 

thanks!


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## mitchellde (Jun 16, 2009)

Wow you are right it is hard with out the right books.  I have Netters and yes I love it .. but for procedure descriptions I really love the "Coder's Desk Reference for Procedures"  It is a little pricey but I really like it, I do not necessarily buy one every year, I wait and look the new codes over first to see if I will need a new one, I can generally get by for a couple of years before I need to update it.  Sometimes at the Barnes and Noble I have been able to find older copies of the Netters book really cheap.  Also if you are wanting to learn anatomy then I really think the best thing you can get is the coloring book.. I taught anatomy at the local college and this was the most valuable book for the students to use to learn from.  I highly recommend it.


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## Justarose (Jun 17, 2009)

great info on the books ! Thank you so much !! 

I can't wait to get myself one or two ... hopefully I can find a good buy somewhere ! 

Thanks !


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