mfournier
Networker
Hello Everyone:
I'm new to orthopedics coding and will like verification on these codes.
Provider provided cpt 27236 but then I provided the cpt description of the 27236 and he stated (did a intramedullary nail) and therefore use 27245.
I see he he made a small incision, also he inserted the pin percutaneously. The only time I see subcutaneous is at the end of the op note.
So confusing.
Pre-operative diagnosis: Left femur intertrochanteric fracture
Post-operative diagnosis: Left femur intertrochanteric fracture
Indications: This is a pleasant 69 year old female who sustained a fall from standing 1 week ago. Patient was unable to bear weight on the left side at the time and presented to the emergency department. Radiographs and a CT scan of the hip at that time were positive for a displaced greater trochanteric fracture. Nonoperative treatment was recommended at the time and the patient was discharged home. Due to persistent pain and inability to walk she presented back to emergency department 1 day ago at which point an MRI was obtained and demonstrated intertrochanteric extension of the fracture. The patient was subsequently admitted to internal medicine and cleared for surgery today. She is ambulatory at baseline with no walking aids. Risks, benefits and alternatives to a left hip intramedullary nail were reviewed and discussed with patient. A consent form was obtained. We discussed possible complications including but not limited to hardware failure, nonunion, malunion, infection, allergy to any of the anesthesia components, pulmonary embolism, deep vein thrombosis, myocardial infarction, death.
Procedure: Patient was identified by the surgical team in the pre-operative holding area and brought into the OR where general anesthesia was administered. Patient was transferred to a fracture table and all bony prominences were adequately padded. Fluoroscopy was brought into the room. Adequate imaging was confirmed in both the AP and lateral views. A timeout was performed. The operative area was subsequently prepped and draped in usual fashion. A small incision just proximal to the greater trochanteric area was performed. A guide pin was inserted percutaneously to a starting point at the tip of the greater trochanter and subsequently tapped in gently. Once adequate positioning was confirmed, an entry reamer was used on the greater trochanter. The entry reamer was subsequently removed along with the guidepin. A 180 mm x 11 mm nail with 125 degrees neck shaft angle was opened and inserted down the proximal femur. Attention was turned to the cephalomedullary component. A guidewire was introduced through the center of the neck and subsequently drilled and measured to an adequate tip-apex distance. The guidepin was measured and a 85 mm lag screw was selected and introduced to the proximal femur. The leg screw was dynamically locked to the nail. Finally, using the same aiming arm used for the leg screw, a 5 mm distal interlocking screw was used to lock the nail distally in a dynamic position. Fluoroscopy was used in every step of the procedure to confirm adequate implant positioning in both the AP and lateral views and final imaging was obtained in the AP and lateral planes confirming adequate positioning. The wounds were copiously irrigated. Vycril sutures was used for the subcutaneous layers and staples for the skin. Three small mepilex dressings were applied. Patient was transferred to the hospital bed and awoken from anesthesia without complications.
Implants: Stryker gamma three 180 x 100 x 125 degrees intramedullary nail, 10.5 x 85 mm lag screw, 5 x 35 mm distal interlocking screw.
Post-operative plan:
- Weight bearing as tolerated
- PT/OT to sit patient up, dangle legs and bear weight as tolerated
- No hip precautions
- ASA 81mg bid for 4 weeks for DVT ppx
- Ok for diet as tolerated
- Pain control per primary team
- Follow-up in clinic in 3 weeks for wound check and new x-rays
Any clarification would be greatly appreciated.
Thanks,
MFournier
I'm new to orthopedics coding and will like verification on these codes.
Provider provided cpt 27236 but then I provided the cpt description of the 27236 and he stated (did a intramedullary nail) and therefore use 27245.
I see he he made a small incision, also he inserted the pin percutaneously. The only time I see subcutaneous is at the end of the op note.
So confusing.
Pre-operative diagnosis: Left femur intertrochanteric fracture
Post-operative diagnosis: Left femur intertrochanteric fracture
Indications: This is a pleasant 69 year old female who sustained a fall from standing 1 week ago. Patient was unable to bear weight on the left side at the time and presented to the emergency department. Radiographs and a CT scan of the hip at that time were positive for a displaced greater trochanteric fracture. Nonoperative treatment was recommended at the time and the patient was discharged home. Due to persistent pain and inability to walk she presented back to emergency department 1 day ago at which point an MRI was obtained and demonstrated intertrochanteric extension of the fracture. The patient was subsequently admitted to internal medicine and cleared for surgery today. She is ambulatory at baseline with no walking aids. Risks, benefits and alternatives to a left hip intramedullary nail were reviewed and discussed with patient. A consent form was obtained. We discussed possible complications including but not limited to hardware failure, nonunion, malunion, infection, allergy to any of the anesthesia components, pulmonary embolism, deep vein thrombosis, myocardial infarction, death.
Procedure: Patient was identified by the surgical team in the pre-operative holding area and brought into the OR where general anesthesia was administered. Patient was transferred to a fracture table and all bony prominences were adequately padded. Fluoroscopy was brought into the room. Adequate imaging was confirmed in both the AP and lateral views. A timeout was performed. The operative area was subsequently prepped and draped in usual fashion. A small incision just proximal to the greater trochanteric area was performed. A guide pin was inserted percutaneously to a starting point at the tip of the greater trochanter and subsequently tapped in gently. Once adequate positioning was confirmed, an entry reamer was used on the greater trochanter. The entry reamer was subsequently removed along with the guidepin. A 180 mm x 11 mm nail with 125 degrees neck shaft angle was opened and inserted down the proximal femur. Attention was turned to the cephalomedullary component. A guidewire was introduced through the center of the neck and subsequently drilled and measured to an adequate tip-apex distance. The guidepin was measured and a 85 mm lag screw was selected and introduced to the proximal femur. The leg screw was dynamically locked to the nail. Finally, using the same aiming arm used for the leg screw, a 5 mm distal interlocking screw was used to lock the nail distally in a dynamic position. Fluoroscopy was used in every step of the procedure to confirm adequate implant positioning in both the AP and lateral views and final imaging was obtained in the AP and lateral planes confirming adequate positioning. The wounds were copiously irrigated. Vycril sutures was used for the subcutaneous layers and staples for the skin. Three small mepilex dressings were applied. Patient was transferred to the hospital bed and awoken from anesthesia without complications.
Implants: Stryker gamma three 180 x 100 x 125 degrees intramedullary nail, 10.5 x 85 mm lag screw, 5 x 35 mm distal interlocking screw.
Post-operative plan:
- Weight bearing as tolerated
- PT/OT to sit patient up, dangle legs and bear weight as tolerated
- No hip precautions
- ASA 81mg bid for 4 weeks for DVT ppx
- Ok for diet as tolerated
- Pain control per primary team
- Follow-up in clinic in 3 weeks for wound check and new x-rays
Any clarification would be greatly appreciated.
Thanks,
MFournier