jenmar
Networker
Please help with this op note. I'm trying to determine if I should code 28297 Lapidus procedure or 28296 & 28740 bunionectomy w/osteotomy & arthrodesis. Doc does say he used a sagittal saw to remove the large bony prominence of the first metatarsal head medially. Is this considered an osteotomy? Feet are my least favorite thing to code.Thanks!!!
DESCRIPTION OF PROCEDURE: In detail, the patient was first identified by
myself and brought into the operating room. Spinal anesthesia was achieved.
The patient was placed on the operating room table in the normal supine
position. The left lower extremity was scrubbed, prepped and draped in a
normal sterile manner. Prior to that, a well-padded pneumatic thigh
tourniquet was applied to the left thigh. The left foot was elevated and
exsanguinated and the pneumatic thigh tourniquet inflated. Attention was
then directed to the medial aspect of the left foot where an incision was
made starting from the central aspect of the medial cuneiform extending
distally to mid shaft of the proximal phalanx of the hallux with care being
taken to stay medial to the extensor hallucis longus tendon. The incision
was deepened through subcutaneous tissues, care being taken to avoid all
vital neurovascular structures and to cauterize all bleeders. Subcutaneous
tissue layers were freed both medially and laterally. A linear capsulotomy
was performed over the first MPJ within the same line as the original skin
incision. The capsule was reflected back both medially and laterally. A
lateral release was performed by transecting the abductor hallucis tendon.
Dissection was carried out to ensure both sesamoids were freed of adhesions
to the plantar surface of the first metatarsal head. McGlamry elevator was
utilized to ensure this had been accomplished. Sagittal saw was utilized
to remove the large bony prominence of the first metatarsal head medially.
Attention was then directed to the first metatarsocuneiform joint where a
linear capsular incision was made with these deep tissues reflected
medially and laterally, exposing the metatarsal cuneiform joint. Sagittal
saw was utilized to resect the cartilage at the base of the first
metatarsal and at the distal aspect of the cuneiform. Tricortical graft
was remodeled to fit in the fusion site to allow for spacing and angular
correction. A 3.0 mm cannulated screw was inserted from distal to proximal
for compression across the fusion site. LPS Wright Medical plate was then
placed over the fusion site and temporarily held in place with a threaded
olive pin and then fixed in place with 2.7 mm screws. Throughout the
process, intraoperative C-arm x-ray was utilized to confirm adequate
reduction of the deformity. Intraoperatively, the patient was observed to
have a high proximal articular set angle. Given as a modified review, the
procedure was performed with the sagittal saw utilized to remove the wedge
of bone that had been created with the cuts. A plantar shelf protected the
sesamoids. The wedge was removed with the capital fragment relocated with
the __________ having been corrected. Fixation was achieved with a 2.0 mm
cannulated screw from proximal to distal. The wound was irrigated with
copious amounts of sterile normal saline. Capsular tissues were
reapproximated using 2-0 Vicryl, subcutaneous tissues were reapproximated
using 4-0 Vicryl, skin was reapproximated utilizing 4-0 Monocryl with a
running intradermal suture technique. The wound was dressed with sterile
Xeroform, 4x4s, Kerlix. Webril was applied and posterior splint was
applied to the left lower extremity, fixed in place with Ace bandages. The
patient tolerated the anesthesia and procedure well and was transported
from the OR to the PACU with vital signs stable and neurovascular status to
the operative foot returned to preop levels. She will be sent home with
instructions to keep her bandages clean, dry, and intact. She was told to
call with any questions and to follow-up in 1 week. A prescription for
pain medication was given.
PATHOLOGY: Bone.