# Need 2nd opinion on elbow surgery



## bethebest7 (May 1, 2012)

Attached scrubbed op note:  Dr is suggesting 24359, 64718 and 24305.  When I read the report, the 24305 area seems incidental and lacking details regarding the procedure.  He was already in the elbow so I don't think it would qualify for -59 since it bundles to the 64718.  I would appreciate any opinions.  I underlined the area that I have doubts.  My thought is:  

DX 726.32; 354.2
Procedures: 24359, 64718

A linear incision was placed over the lateral epicondyle.  Blunt dissection was performed.  The lateral antebrachial cutaneous nerve was carefully retracted.  An incision line was then placed at the interval between the mobile wad and the EDC.  This allowed reflection of the mobile wad attachment as well as the EDC off of the lateral epicondyle.  Once this was completed, the lateral epicondyle was débrided down to a good cancellous bed that was well vascularized.  After a thorough irrigation, the attachment was then repaired side-to-side using 3-0 FiberWire.  The skin was closed using 2-0 Vicryl and staples.

Attention was then directed to the medial elbow where a curvilinear incision was placed along the medial aspect of the elbow centered between the medial epicondyle anteriorly and the tip of the olecranon posteriorly.  Blunt dissection was performed.  The basilic vein and the medial antebrachial cutaneous nerve were carefully retracted.  The ulnar nerve was isolated.  Dissection was then proceeded proximal through the arcade of Struthers.  Nerve dissection then proceeded distal through the Osborne's ligament and deep between the two heads of the FCU, releasing the profundus fascia overlying the nerve.  Once the neurolysis was completed, the nerve was transposed anteriorly.  A fascial flap was then constructed out of the flexor-pronator fascia, keeping it proximally based.  After the nerve was transposed, this was sutured into the subcutaneous tissue of the anterior skin flap to prevent posterior subluxation of the nerve.  Care was taken when suturing this not to incarcerate any of the small branches of the medial antebrachial cutaneous nerve.  Once this was completed, the elbow was placed through a full range of motion.  There were no areas of kinking or impingement of the ulnar nerve.  The distal portion of the medial intermuscular septum was also excised to prevent this as being a site of recurrent compression.

Attention was then directed to the proximal attachment of the flexor-pronator muscle mass.  The fascial band attachment was divided leaving the muscle intact, a so called fractional lengthening of the muscle.

Thanks, 
Brenda Coughlin, B.S., CPC


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