Hi list! Still newbie learning these surgeries. First time coming across one like this. Can someone please validate my codes and I am not sure about the diagnosis coding as well. Help please
JM,CCS,CPC
POSTOPERATIVE DIAGNOSIS:
Right type 2B distal clavicle fracture with AC joint and CC
ligament disruption.
PROCEDURES:
1. Open reduction and internal fixation of right distal
clavicle fracture (23515).
2. Open reconstruction, right AC joint/CC ligament disruption
(23550).
3. Diagnostic arthroscopy, right shoulder (29805).
SURGEON:
ASSISTANT:
was crucial for the entirety of the
procedure. There was no qualified resident available.
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
100 mL.
IV FLUIDS:
1400 mL.
INDICATIONS FOR PROCEDURE:
The patient is a 52-year-old left hand dominant female who
fell down the stairs on May 25, 2015, directly onto her right
shoulder where she felt immediate pain, ecchymosis and
discomfort. She was seen in the clinic and diagnosed with a
distal clavicle fracture with CC ligament disruption with a type 2B
fracture with significant displacement that was unlikely to
heal without operative intervention. She understood the risks
and benefits of operative intervention and agreed to proceed
with surgery today.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed supine
on the OR table, underwent general anesthesia. Difficulty
Preop time-out was done, identifying her right shoulder as the
operative shoulder. She was placed in the beach chair
position with all bony prominences padded. She was prepped
and draped in sterile fashion using ChloraPrep. We first
began with the diagnostic arthroscopy through a posterior
portal. We made an anterior superolateral portal and
cannulated it with an 8.25 mm cannula in order to access the
coracoid. The diagnostic arthroscopy showed an intact biceps
tendon, some mild fraying of the superior labrum, but no
evidence of a SLAP tear. There was no anterior, posterior
Bankart tear. The subscapularis and supraspinatus were both
intact. There was no chondromalacia on either the humeral
head or glenoid. We then used the electrocautery to clear off
the base of the coracoid process using both a 30 and 70-degree
scope from the posterior portal. Once this was accomplished,
we then switched our camera to the anterior superolateral
portal and cleaned the rest of the base of the coracoid off
after making an anterior portal just off the coricoid tip.
This gave us excellent access for AC joint reduction hardware
later in the case. We then made a curvilinear 8 cm incision
over the distal clavicle. We identified both the medial and
lateral fracture fragments. The lateral fragment was very
small oblique and comminuted. Multiple K-wires were placed
for provisional reduction, but really the bone quality did not
allow very good reduction at all. We then placed an Arthrex
locking distal clavicle plate and provisionally fixed it with
K-wires proximally and distally verifying with the C-arm
adequate reduction. Multiple attempts were made using locking
screws in the lateral piece; however, the piece again was too
comminuted for locking screws, we were only able to get one central
3.0 cancellous screws in the distal fragment. We therefore
used a cerclage technique with four #2 FiberWire stitches that
were thrown through the fracture fragment soft tissue and the
plate to help fix the distal fragment. We then placed three
cortical screws medially with good reduction of the fracture
and good capture of the plate to the clavicle. We verified
the reduction to be good on the C-arm image intensifier. We
then used our dog bone guide and drilled through the clavicle
and the coracoid. We passed our dog bone fixation device
through the anterior portal and through the Pilot holes on
both the coracoid and the clavicle. We then used the button
that fitted into the plate in order to tension the fiber tape
over the clavicle. The reduction was maintained with lateral
pressure over the plate and both FiberTape were tied down with
4 knots. This gave us excellent stable fixation of the CC
ligaments and helped aid the reduction of the fracture. We
then tied the knot stack through the plate. The wound was
copiously irrigated. We used 0-Vicryl stitches in a
figure-of-eight fashion on the deep layer, 2-0 Vicryl on the
subcutaneous layer and a running 3-0 Prolene on the skin. All
other portals were closed using interrupted nylon stitches.
Xeroform was placed over the portals and Steri-Strips over the
clavicle incision. Dressing sponges, ABD, foam tape and an
UltraSling were applied. The patient tolerated the procedure
well and transferred to recovery room in stable condition.
Postoperatively, she is to maintain a sling at all times for
the first 4 weeks on her right upper extremity. We will see
her back in clinic in 10-14 days for repeat evaluation and
suture removal.
JM,CCS,CPC
POSTOPERATIVE DIAGNOSIS:
Right type 2B distal clavicle fracture with AC joint and CC
ligament disruption.
PROCEDURES:
1. Open reduction and internal fixation of right distal
clavicle fracture (23515).
2. Open reconstruction, right AC joint/CC ligament disruption
(23550).
3. Diagnostic arthroscopy, right shoulder (29805).
SURGEON:
ASSISTANT:
was crucial for the entirety of the
procedure. There was no qualified resident available.
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
100 mL.
IV FLUIDS:
1400 mL.
INDICATIONS FOR PROCEDURE:
The patient is a 52-year-old left hand dominant female who
fell down the stairs on May 25, 2015, directly onto her right
shoulder where she felt immediate pain, ecchymosis and
discomfort. She was seen in the clinic and diagnosed with a
distal clavicle fracture with CC ligament disruption with a type 2B
fracture with significant displacement that was unlikely to
heal without operative intervention. She understood the risks
and benefits of operative intervention and agreed to proceed
with surgery today.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed supine
on the OR table, underwent general anesthesia. Difficulty
Preop time-out was done, identifying her right shoulder as the
operative shoulder. She was placed in the beach chair
position with all bony prominences padded. She was prepped
and draped in sterile fashion using ChloraPrep. We first
began with the diagnostic arthroscopy through a posterior
portal. We made an anterior superolateral portal and
cannulated it with an 8.25 mm cannula in order to access the
coracoid. The diagnostic arthroscopy showed an intact biceps
tendon, some mild fraying of the superior labrum, but no
evidence of a SLAP tear. There was no anterior, posterior
Bankart tear. The subscapularis and supraspinatus were both
intact. There was no chondromalacia on either the humeral
head or glenoid. We then used the electrocautery to clear off
the base of the coracoid process using both a 30 and 70-degree
scope from the posterior portal. Once this was accomplished,
we then switched our camera to the anterior superolateral
portal and cleaned the rest of the base of the coracoid off
after making an anterior portal just off the coricoid tip.
This gave us excellent access for AC joint reduction hardware
later in the case. We then made a curvilinear 8 cm incision
over the distal clavicle. We identified both the medial and
lateral fracture fragments. The lateral fragment was very
small oblique and comminuted. Multiple K-wires were placed
for provisional reduction, but really the bone quality did not
allow very good reduction at all. We then placed an Arthrex
locking distal clavicle plate and provisionally fixed it with
K-wires proximally and distally verifying with the C-arm
adequate reduction. Multiple attempts were made using locking
screws in the lateral piece; however, the piece again was too
comminuted for locking screws, we were only able to get one central
3.0 cancellous screws in the distal fragment. We therefore
used a cerclage technique with four #2 FiberWire stitches that
were thrown through the fracture fragment soft tissue and the
plate to help fix the distal fragment. We then placed three
cortical screws medially with good reduction of the fracture
and good capture of the plate to the clavicle. We verified
the reduction to be good on the C-arm image intensifier. We
then used our dog bone guide and drilled through the clavicle
and the coracoid. We passed our dog bone fixation device
through the anterior portal and through the Pilot holes on
both the coracoid and the clavicle. We then used the button
that fitted into the plate in order to tension the fiber tape
over the clavicle. The reduction was maintained with lateral
pressure over the plate and both FiberTape were tied down with
4 knots. This gave us excellent stable fixation of the CC
ligaments and helped aid the reduction of the fracture. We
then tied the knot stack through the plate. The wound was
copiously irrigated. We used 0-Vicryl stitches in a
figure-of-eight fashion on the deep layer, 2-0 Vicryl on the
subcutaneous layer and a running 3-0 Prolene on the skin. All
other portals were closed using interrupted nylon stitches.
Xeroform was placed over the portals and Steri-Strips over the
clavicle incision. Dressing sponges, ABD, foam tape and an
UltraSling were applied. The patient tolerated the procedure
well and transferred to recovery room in stable condition.
Postoperatively, she is to maintain a sling at all times for
the first 4 weeks on her right upper extremity. We will see
her back in clinic in 10-14 days for repeat evaluation and
suture removal.