pittiemom2722
Guru
I am a bit lost on this surgery, can someone give guidance on coding this???? I would SO greatly appreciate it!!! Is it unlisted? Just an open arthrotomy? Help 
Pre Op Dx:
M19.071 (ICD-10-CM) - Primary osteoarthritis, right ankle and foot
Z96.661 (ICD-10-CM) - Presence of right artificial ankle joint
Post Op Dx:
Same
Right ankle gutter impingement, medial and lateral
Procedure:
Medial and lateral right ankle joint gutter debridement, bony debridement, peroneal and posterior tibial tendon exploration
Procedure Description:
Patient is taken operative placed supine on operative table. After appropriate anesthesia was administered, appropriate bumping padding was performed and the affected lower extremities prepped draped usual sterile fashion. Time-out procedures were followed. Thigh tourniquet was inflated and a curvilinear anterior medial approach to the medial gutter of the right ankle was performed. Very careful dissection carried down through subcutaneous tissue avoid injury to neurovascular structures. Saphenous nerve was protected. The posterior tibialis tendon was evaluated as it curved around the medial malleolus and found to be intact without evidence of tearing, tendinosis or significant synovitis. The medial ankle gutter was evaluated there was severe bony impingement and this was extensively debrided both on the talus and medial malleolar side utilizing Ronguers and osteotomes. Debridement was carried out from anterior to posterior and included the entire gutter to the point where there was no evidence of any further bony impingement. This improved ankle motion by approximally 3-5 degrees. The ankle appeared to be stable without evidence of gross instability of the talar component which could be visualized through this incision. There was no evidence of infection or cystic changes in this area of the bone. C-arm image intensification confirmed satisfactory bony resection. Bony resection was carried out in the area of the patient's maximum preoperative symptoms. There was no evidence of stress fracture or reaction about the medial malleolus. The wound was thoroughly irrigated and bone wax was placed over the cancellous bone in the talus and medial malleolus. The integrity of the medial malleolus was maintained. The wound was closed with interrupted 2 0 chromic suture in the capsular tissue and subcutaneous tissue and interrupted 4-0 nylon suture in the skin. Next a curvilinear anterior lateral incision was made about the lateral gutter extending over the tip of the lateral malleolus. Very careful dissection carried down through subcutaneous tissue to avoid injury to neurovascular structures and the peroneal tendons the peroneal tendons were evaluated at the tip of the lateral malleolus and found to be intact without evidence of tearing or synovitis. There was bony impingement and buildup about the tip of the lateral malleolus which was debrided with Ronguers and osteotomes.
The prosthesis appeared stable in this incision as it could be evaluated. There was no evidence of gross ankle or implant instability. There was no evidence of infection and after bony resection there was no further evidence of bony impingement.
This wound was thoroughly irrigated and bone wax was placed over the cancellous bony surfaces. The wound was closed with interrupted 2 0 chromic suture in the capsular tissue and interrupted 4-0 nylon suture in the skin. 0.5% Marcaine was instilled proximal to both wounds. Soft sterile bulky dressings incorporating plaster splints holding Foot and Ankle neutral position were applied. Patient was reversed anesthesia and taken recovery room good condition
Pre Op Dx:
M19.071 (ICD-10-CM) - Primary osteoarthritis, right ankle and foot
Z96.661 (ICD-10-CM) - Presence of right artificial ankle joint
Post Op Dx:
Same
Right ankle gutter impingement, medial and lateral
Procedure:
Medial and lateral right ankle joint gutter debridement, bony debridement, peroneal and posterior tibial tendon exploration
Procedure Description:
Patient is taken operative placed supine on operative table. After appropriate anesthesia was administered, appropriate bumping padding was performed and the affected lower extremities prepped draped usual sterile fashion. Time-out procedures were followed. Thigh tourniquet was inflated and a curvilinear anterior medial approach to the medial gutter of the right ankle was performed. Very careful dissection carried down through subcutaneous tissue avoid injury to neurovascular structures. Saphenous nerve was protected. The posterior tibialis tendon was evaluated as it curved around the medial malleolus and found to be intact without evidence of tearing, tendinosis or significant synovitis. The medial ankle gutter was evaluated there was severe bony impingement and this was extensively debrided both on the talus and medial malleolar side utilizing Ronguers and osteotomes. Debridement was carried out from anterior to posterior and included the entire gutter to the point where there was no evidence of any further bony impingement. This improved ankle motion by approximally 3-5 degrees. The ankle appeared to be stable without evidence of gross instability of the talar component which could be visualized through this incision. There was no evidence of infection or cystic changes in this area of the bone. C-arm image intensification confirmed satisfactory bony resection. Bony resection was carried out in the area of the patient's maximum preoperative symptoms. There was no evidence of stress fracture or reaction about the medial malleolus. The wound was thoroughly irrigated and bone wax was placed over the cancellous bone in the talus and medial malleolus. The integrity of the medial malleolus was maintained. The wound was closed with interrupted 2 0 chromic suture in the capsular tissue and subcutaneous tissue and interrupted 4-0 nylon suture in the skin. Next a curvilinear anterior lateral incision was made about the lateral gutter extending over the tip of the lateral malleolus. Very careful dissection carried down through subcutaneous tissue to avoid injury to neurovascular structures and the peroneal tendons the peroneal tendons were evaluated at the tip of the lateral malleolus and found to be intact without evidence of tearing or synovitis. There was bony impingement and buildup about the tip of the lateral malleolus which was debrided with Ronguers and osteotomes.
The prosthesis appeared stable in this incision as it could be evaluated. There was no evidence of gross ankle or implant instability. There was no evidence of infection and after bony resection there was no further evidence of bony impingement.
This wound was thoroughly irrigated and bone wax was placed over the cancellous bony surfaces. The wound was closed with interrupted 2 0 chromic suture in the capsular tissue and interrupted 4-0 nylon suture in the skin. 0.5% Marcaine was instilled proximal to both wounds. Soft sterile bulky dressings incorporating plaster splints holding Foot and Ankle neutral position were applied. Patient was reversed anesthesia and taken recovery room good condition