tschrader
Networker
The provider coded 64718 and 24546. This is hitting up with CCI edits 64718 is needing a modifier. 24546 states that the ulnar nerve is moved so I could see where 64718 would be considered bundled.
Heres the op note:
PRE-OPERATIVE DIAGNOSIS:
1. Left supracondylar humerus fracture with intra-articular extension.
2. Left olecranon fracture.
POST-OPERATIVE DIAGNOSIS:
Same.
NAME OF OPERATION:
1. Open reduction/internal fixation supracondylar humerus fracture with intra-articular extension.
2. Open reduction/internal fixation left olecranon fracture.
3. Subcutaneous transposition of ulnar nerve.
ANESTHESIA:
General endotracheal intubation.
FLUIDS:
1,100 cc of Crystalloid.
ESTIMATED BLOOD LOSS:
100 cc.
URINE OUTPUT:
300 cc.
INDICATIONS FOR PROCEDURE:
Mr is an unfortunate 65-year-old male with multiple medical comorbidities who sustained a ground level fall. He landed on his left upper extremity. He had immediate pain in his left arm. The patient was initially seen by an outside Emergency Room and orthopedic surgeon. He was splinted and instructed to follow up with me from Parsons, Kansas for care. I saw Mr. in my office with his wife. At that time, treatment
options were discussed at length. These did include both operative and nonoperative intervention. Complications, risks and benefits of both were discussed at length. Mr. was requesting surgical intervention after we thoroughly discussed the complication and risk of the procedure. I first scheduled Mr. for an evaluation by his primary care physician for preoperative risk ratification and clearance as he has a significant
cardiac history. did receive that, returned to my office one week later and was again requesting surgical intervention. He was scheduled for surgery on 05/19/2014.
PROCEDURE IN DETAIL:
was met in the holding area. Operative extremity was marked in accordance with preoperative H and P, informed consent. The patient was then transferred to the OR by the Department of Anesthesia. Once in the OR, he was transferred off the gurney and onto the operative table. He was secured to the bed with a lap belt. Once the patient was on the operative table, he was properly anesthetized by the Department of Anesthesia. Once the patient was asleep, he was then positioned in the lateral position with the aid of a beanbag. All bony prominences were well padded and an axillary roll was placed. Foley catheter was inserted by the nursing staff. Tourniquet was then applied to his left arm and the left upper extremity was prepped and draped in the usual orthopedic sterile fashion. Surgical time-out was then held and included the patient's name, surgical site, procedure to be performed. All were correct and Mr. was receiving appropriate preoperative antibiotics. After the time-out, the left upper extremity was exsanguinated and the tourniquet was inflated.
Longitudinal incision was made centered on the posterior humerus and the olecranon. This was taken down sharply through the skin and subcutaneous tissue. Dissection was carried down through the skin, subcutaneous fascia, down to the level of the triceps fascia. Attention was first turned medially where the ulnar nerve was identified. Dissection was carried out along the ulnar nerve and a 1/4-inch Penrose drain was placed around the ulnar nerve atraumatically. Care was taken to protect the ulnar nerve throughout the entire procedure. Then utilizing para-tricipital approach, the medial border of the triceps was elevated off of the humerus. Hohmann was placed along the posterior aspect of the humerus reflecting the triceps
musculature out of the field. Reduction was performed on the medial side and a Smith and Nephew medial distal humeral locking plate was selected on the back table and slide within the wound. Then placed 2 nonlocking screws on either side of the fracture. This was done in standard technique first drilling, then measuring, then placing the screw by power and finally seating by hand. These 2 screws helped to compress the plate to the
bone. Distally, I then put 2 locking screws through the distal cluster utilizing the appropriate drill guide and drill. These 2 locking screws were found to be of appropriate length and outside of the joint. Proximally I then placed 2 more additional nonlocking cortical screws through this plate. These screws were placed in standard technique as described above. Fluoroscopy confirmed that they were of appropriate length. These screws
had excellent purchase in the far cortex. I then removed my initial nonlocking cortical screw that was initially placed in the distal cluster. This screw was replaced with a locking screw.
Attention was then turned to the lateral side where a paratricipital approach was used. The triceps was elevated off the lateral border of the humerus. Care was taken not to compress the ulnar nerve with my Hohmann retractor. Fracture was then identified on this side of the humerus. It was provisionally held with a 2.0 K-wire. Then a Smith and Nephew lateral distal humeral locking plate was selected on the back table and slid within the wound. Care was taken not to place the plate overlying the radial nerve. This Smith and Nephew lateral locking plate fit better along the posterior aspect of Mr. humerus. I did attempt to place a posterolateral locking plate along the posterolateral aspect of Mr.s humerus. However, this did not fit well. I elected to proceed with the lateral locking plate along the posterolateral border of Mr. humerus. This plate sat very nicely along his humerus, not requiring any modification. I then placed 2 nonlocking screws through the plate on either side of the fracture. This was done in standard technique first drilling, then measuring, then placing the screw by power and finally seating by hand. These 2 screws helped to compress the plate to the bone and affect a reduction of this lateral fracture fragment. Two locking screws were then placed through the distal cluster with the appropriate drill and drill guide. These screws were found to be of appropriate length and outside of the joint. I then placed 2 additional nonlocking screws through the plate into the proximal fragment. This was done in standard technique as described above. One additional locking screw was then placed in the distal fragment. I removed my initial nonlocking screw distally and replaced this screw with a fully threaded locking screw. Fluoroscopy showed excellent reduction and appropriate position of all hardware. Mr. elbow was taken through a full range of motion which included flexion, extension, pronation and supination and no crepitation was felt.
Attention was then turned to the nondisplaced olecranon fracture. Utilizing a Smith and Nephew olecranon locking plate, this was placed on the tip of the olecranon and the tines were placed into the triceps. K-wires were placed through the 2 proximal K-wire slots and the plate. Fluoroscopy confirmed appropriate position of all hardware. Nonlocking screw was then placed through the plate distally into the shaft. This was done in
standard technique, first drilling, then measuring, then placing the screw by power and finally seating by hand. This screw compressed the plate to the bone as well as compressed the proximal portion of the plate in its tines into the olecranon and the triceps. I then placed an additional screw through the plate to further provide additional fixation. K-wires were then removed and 2 locking screws were placed in the most proximal portion of
the plate down the shaft of the ulna. These screws were done in standard technique utilizing the appropriate drill and drill guide. These screws both measured 50 mm in length. There was excellent compression across the fracture site and the hardware was found to be in appropriate position with biplanar fluoroscopy. Elbow was again taken through a range of motion and the fractures were shown to have no pathological motion and there was no crepitation with elbow range of motion. Wounds were copiously irrigated with 3 liter bag of sterile saline via cysto tubing. Ulnar nerve was then transpositioned subcutaneously.
Subcutaneous tissue was then closed with 0 Vicryl, 2-0 Vicryl and the skin was closed with staples. Dressing consistent of Xeroform, dressing sponges, sterile Webril and a long arm posterior plaster splint. Tourniquet was deflated prior to closure and hemostasis was achieved with electrocautery. All sponge and needle counts were correct and Mr. tolerated the procedure well. He was awoken by Anesthesia. Drapes were removed. He was transferred off the operative table onto the gurney and into PACU in stable condition. Mr. will be nonweightbearing to his left upper extremity.
Any feed back would be great on this! Thanks so much for your help!
Heres the op note:
PRE-OPERATIVE DIAGNOSIS:
1. Left supracondylar humerus fracture with intra-articular extension.
2. Left olecranon fracture.
POST-OPERATIVE DIAGNOSIS:
Same.
NAME OF OPERATION:
1. Open reduction/internal fixation supracondylar humerus fracture with intra-articular extension.
2. Open reduction/internal fixation left olecranon fracture.
3. Subcutaneous transposition of ulnar nerve.
ANESTHESIA:
General endotracheal intubation.
FLUIDS:
1,100 cc of Crystalloid.
ESTIMATED BLOOD LOSS:
100 cc.
URINE OUTPUT:
300 cc.
INDICATIONS FOR PROCEDURE:
Mr is an unfortunate 65-year-old male with multiple medical comorbidities who sustained a ground level fall. He landed on his left upper extremity. He had immediate pain in his left arm. The patient was initially seen by an outside Emergency Room and orthopedic surgeon. He was splinted and instructed to follow up with me from Parsons, Kansas for care. I saw Mr. in my office with his wife. At that time, treatment
options were discussed at length. These did include both operative and nonoperative intervention. Complications, risks and benefits of both were discussed at length. Mr. was requesting surgical intervention after we thoroughly discussed the complication and risk of the procedure. I first scheduled Mr. for an evaluation by his primary care physician for preoperative risk ratification and clearance as he has a significant
cardiac history. did receive that, returned to my office one week later and was again requesting surgical intervention. He was scheduled for surgery on 05/19/2014.
PROCEDURE IN DETAIL:
was met in the holding area. Operative extremity was marked in accordance with preoperative H and P, informed consent. The patient was then transferred to the OR by the Department of Anesthesia. Once in the OR, he was transferred off the gurney and onto the operative table. He was secured to the bed with a lap belt. Once the patient was on the operative table, he was properly anesthetized by the Department of Anesthesia. Once the patient was asleep, he was then positioned in the lateral position with the aid of a beanbag. All bony prominences were well padded and an axillary roll was placed. Foley catheter was inserted by the nursing staff. Tourniquet was then applied to his left arm and the left upper extremity was prepped and draped in the usual orthopedic sterile fashion. Surgical time-out was then held and included the patient's name, surgical site, procedure to be performed. All were correct and Mr. was receiving appropriate preoperative antibiotics. After the time-out, the left upper extremity was exsanguinated and the tourniquet was inflated.
Longitudinal incision was made centered on the posterior humerus and the olecranon. This was taken down sharply through the skin and subcutaneous tissue. Dissection was carried down through the skin, subcutaneous fascia, down to the level of the triceps fascia. Attention was first turned medially where the ulnar nerve was identified. Dissection was carried out along the ulnar nerve and a 1/4-inch Penrose drain was placed around the ulnar nerve atraumatically. Care was taken to protect the ulnar nerve throughout the entire procedure. Then utilizing para-tricipital approach, the medial border of the triceps was elevated off of the humerus. Hohmann was placed along the posterior aspect of the humerus reflecting the triceps
musculature out of the field. Reduction was performed on the medial side and a Smith and Nephew medial distal humeral locking plate was selected on the back table and slide within the wound. Then placed 2 nonlocking screws on either side of the fracture. This was done in standard technique first drilling, then measuring, then placing the screw by power and finally seating by hand. These 2 screws helped to compress the plate to the
bone. Distally, I then put 2 locking screws through the distal cluster utilizing the appropriate drill guide and drill. These 2 locking screws were found to be of appropriate length and outside of the joint. Proximally I then placed 2 more additional nonlocking cortical screws through this plate. These screws were placed in standard technique as described above. Fluoroscopy confirmed that they were of appropriate length. These screws
had excellent purchase in the far cortex. I then removed my initial nonlocking cortical screw that was initially placed in the distal cluster. This screw was replaced with a locking screw.
Attention was then turned to the lateral side where a paratricipital approach was used. The triceps was elevated off the lateral border of the humerus. Care was taken not to compress the ulnar nerve with my Hohmann retractor. Fracture was then identified on this side of the humerus. It was provisionally held with a 2.0 K-wire. Then a Smith and Nephew lateral distal humeral locking plate was selected on the back table and slid within the wound. Care was taken not to place the plate overlying the radial nerve. This Smith and Nephew lateral locking plate fit better along the posterior aspect of Mr. humerus. I did attempt to place a posterolateral locking plate along the posterolateral aspect of Mr.s humerus. However, this did not fit well. I elected to proceed with the lateral locking plate along the posterolateral border of Mr. humerus. This plate sat very nicely along his humerus, not requiring any modification. I then placed 2 nonlocking screws through the plate on either side of the fracture. This was done in standard technique first drilling, then measuring, then placing the screw by power and finally seating by hand. These 2 screws helped to compress the plate to the bone and affect a reduction of this lateral fracture fragment. Two locking screws were then placed through the distal cluster with the appropriate drill and drill guide. These screws were found to be of appropriate length and outside of the joint. I then placed 2 additional nonlocking screws through the plate into the proximal fragment. This was done in standard technique as described above. One additional locking screw was then placed in the distal fragment. I removed my initial nonlocking screw distally and replaced this screw with a fully threaded locking screw. Fluoroscopy showed excellent reduction and appropriate position of all hardware. Mr. elbow was taken through a full range of motion which included flexion, extension, pronation and supination and no crepitation was felt.
Attention was then turned to the nondisplaced olecranon fracture. Utilizing a Smith and Nephew olecranon locking plate, this was placed on the tip of the olecranon and the tines were placed into the triceps. K-wires were placed through the 2 proximal K-wire slots and the plate. Fluoroscopy confirmed appropriate position of all hardware. Nonlocking screw was then placed through the plate distally into the shaft. This was done in
standard technique, first drilling, then measuring, then placing the screw by power and finally seating by hand. This screw compressed the plate to the bone as well as compressed the proximal portion of the plate in its tines into the olecranon and the triceps. I then placed an additional screw through the plate to further provide additional fixation. K-wires were then removed and 2 locking screws were placed in the most proximal portion of
the plate down the shaft of the ulna. These screws were done in standard technique utilizing the appropriate drill and drill guide. These screws both measured 50 mm in length. There was excellent compression across the fracture site and the hardware was found to be in appropriate position with biplanar fluoroscopy. Elbow was again taken through a range of motion and the fractures were shown to have no pathological motion and there was no crepitation with elbow range of motion. Wounds were copiously irrigated with 3 liter bag of sterile saline via cysto tubing. Ulnar nerve was then transpositioned subcutaneously.
Subcutaneous tissue was then closed with 0 Vicryl, 2-0 Vicryl and the skin was closed with staples. Dressing consistent of Xeroform, dressing sponges, sterile Webril and a long arm posterior plaster splint. Tourniquet was deflated prior to closure and hemostasis was achieved with electrocautery. All sponge and needle counts were correct and Mr. tolerated the procedure well. He was awoken by Anesthesia. Drapes were removed. He was transferred off the operative table onto the gurney and into PACU in stable condition. Mr. will be nonweightbearing to his left upper extremity.
Any feed back would be great on this! Thanks so much for your help!
