Can one infer that a ganglion was removed based on the physician stating “We then used the shaver, and a dorsal capsulectomy was performed, visualizing the EPL and the second wrist extensor compartment. At this point, spinal arthroscopic pictures were taken, and excess fluid was expressed?
There is no explicit mention of visualization of a ganglion in the description of procedure, and I am wondering how the use of a ganglion diagnosis code is appropriate without the mention in the body.
My thought is to query the physician to clarify if the dorsal capsulectomy also addressed the excision of the ganglion, however I wanted to ask if maybe there is something I am not picking up on, prior to proceeding.
POSTOPERATIVE DIAGNOSIS: Right dorsal recurrent ganglion cyst with persistent wrist pain. PROCEDURES PERFORMED: Right wrist arthroscopic debridement and ganglion cyst excision with synovectomy and debridement of the scapholunate ligament.
INDICATIONS: The patient presents with symptomatic right wrist pain and recurrent ganglion cyst after previous open cyst excision. He has failed nonoperative treatment and elects to proceed. Risks, benefits, and alternatives were discussed with the patient and he elects to proceed. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine with the right hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. Timeout was performed and preoperative antibiotics were given. The patient was placed into the wrist arthroscopy tower, and a 3-4 portal was established, and the scope was placed into the joint. We initially tried a dry arthroscopy, but there was significant synovitis and difficulty with visualization. So, at this point, a 6R portal was established, and synovectomy and debridement of the joint was performed. We did establish a 1-2 portal because of significant synovitis along the radial gutter. The TFCC was intact. There was some fraying and partial tearing of the scapholunate ligament, and a shrinker probe was selected and was used to debride the scapholunate ligament. We then used the shaver, and a dorsal capsulectomy was performed, visualizing the EPL and the second wrist extensor compartment. At this point, spinal arthroscopic pictures were taken, and excess fluid was expressed. The portals were closed with 4-0 nylon sutures, and a dorsal wrist splint was applied.
There is no explicit mention of visualization of a ganglion in the description of procedure, and I am wondering how the use of a ganglion diagnosis code is appropriate without the mention in the body.
My thought is to query the physician to clarify if the dorsal capsulectomy also addressed the excision of the ganglion, however I wanted to ask if maybe there is something I am not picking up on, prior to proceeding.
POSTOPERATIVE DIAGNOSIS: Right dorsal recurrent ganglion cyst with persistent wrist pain. PROCEDURES PERFORMED: Right wrist arthroscopic debridement and ganglion cyst excision with synovectomy and debridement of the scapholunate ligament.
INDICATIONS: The patient presents with symptomatic right wrist pain and recurrent ganglion cyst after previous open cyst excision. He has failed nonoperative treatment and elects to proceed. Risks, benefits, and alternatives were discussed with the patient and he elects to proceed. Informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine with the right hand on the hand table. Anesthesia was induced. The arm was then prepped and draped in normal sterile fashion. Timeout was performed and preoperative antibiotics were given. The patient was placed into the wrist arthroscopy tower, and a 3-4 portal was established, and the scope was placed into the joint. We initially tried a dry arthroscopy, but there was significant synovitis and difficulty with visualization. So, at this point, a 6R portal was established, and synovectomy and debridement of the joint was performed. We did establish a 1-2 portal because of significant synovitis along the radial gutter. The TFCC was intact. There was some fraying and partial tearing of the scapholunate ligament, and a shrinker probe was selected and was used to debride the scapholunate ligament. We then used the shaver, and a dorsal capsulectomy was performed, visualizing the EPL and the second wrist extensor compartment. At this point, spinal arthroscopic pictures were taken, and excess fluid was expressed. The portals were closed with 4-0 nylon sutures, and a dorsal wrist splint was applied.