26432 VS 26433 The description of the op note says " open " but I am not seeing an incision made?? Any takers??
TIA
jmb,ccs,cpc
PREOPERATIVE DIAGNOSES:
1. Left chronic open Mallet finger
POSTOPERATIVE DIAGNOSES:
Same
OPERATIONS PERFORMED:
Open reduction and internal fixation Left open mallet finger/ extensor tendon insertion.
TOURNIQUET TIME:
none
ESTIMATED BLOOD LOSS:
minimal.
FLUIDS:
Per anesthesia record.
OPERATIVE FINDINGS:
45 degree Left index chronic soft tissue open mallet/ extensor lag with PIP early Swan Neck deformity. Mild retraction
OPERATIVE SUMMARY IN DETAIL:
Following appropriate informed consent, patient identification, and operative limb, the patient was brought to the operating suite where smooth induction of LMA anesthesia was accomplished by the anesthesiology service. Broad spectrum IV antibiotic prophylaxis was given. The upper extremity was prepped and draped in the usually fashion and a time out was performed identifying patient, limb(s) and procedure(s). The extensor insertion and DIP was then visualized using a radial flap incorporating the old scar over the DIP.The DIP joint was not subluxed. The extensor insertion was lacerated and mildly retracted. The tendon was debrided and Internal fixation with an intramedullary .045 inch wire in slight DIP hyperextension and a mini Mitek suture anchor was performed. The wires were cut off below the skin for low profile position. Anatomic alignment was noted clinically and using fluoroscopy. Reduction and hardware placement was satisfactory. Pin sites were sealed with Dermabond. Marcaine was used to perform a digital block for perioperative pain relief. A sterile non adherent dressing was applied. The patient was extubated and transferred to the recovery area with a warm, viable hand and digits times five. There were no intraoperative complications and the patient tolerated the procedure well
TIA
jmb,ccs,cpc
PREOPERATIVE DIAGNOSES:
1. Left chronic open Mallet finger
POSTOPERATIVE DIAGNOSES:
Same
OPERATIONS PERFORMED:
Open reduction and internal fixation Left open mallet finger/ extensor tendon insertion.
TOURNIQUET TIME:
none
ESTIMATED BLOOD LOSS:
minimal.
FLUIDS:
Per anesthesia record.
OPERATIVE FINDINGS:
45 degree Left index chronic soft tissue open mallet/ extensor lag with PIP early Swan Neck deformity. Mild retraction
OPERATIVE SUMMARY IN DETAIL:
Following appropriate informed consent, patient identification, and operative limb, the patient was brought to the operating suite where smooth induction of LMA anesthesia was accomplished by the anesthesiology service. Broad spectrum IV antibiotic prophylaxis was given. The upper extremity was prepped and draped in the usually fashion and a time out was performed identifying patient, limb(s) and procedure(s). The extensor insertion and DIP was then visualized using a radial flap incorporating the old scar over the DIP.The DIP joint was not subluxed. The extensor insertion was lacerated and mildly retracted. The tendon was debrided and Internal fixation with an intramedullary .045 inch wire in slight DIP hyperextension and a mini Mitek suture anchor was performed. The wires were cut off below the skin for low profile position. Anatomic alignment was noted clinically and using fluoroscopy. Reduction and hardware placement was satisfactory. Pin sites were sealed with Dermabond. Marcaine was used to perform a digital block for perioperative pain relief. A sterile non adherent dressing was applied. The patient was extubated and transferred to the recovery area with a warm, viable hand and digits times five. There were no intraoperative complications and the patient tolerated the procedure well