skires06
New
Need help! Need to know what cpt code I would use for this op report for the ligament reconstruction. It looks like he removed the original device and put it back after seeing that it did not need any type of repair or replacing. What code would you use?
As for the allograft injection to the lt thumb I believe I would use 17999 (compared to 15777).
Here is the op report:
Indications: this patient has a previously placed right CMC joint ligament reconstruction device as well as a recent CMC arthroplasty. She has significant improvement in pain to her CMC region however there is some tightness at the CMC joint from the first to second metacarpal. On evaluation appears that her ligament reconstruction is too tight and we discussed the options of evaluating it in the operating room with removal and reevaluation as to whether the ligament reconstruction was required or if there was enough stability without the device in place. She also has a history of left thumb interphalangeal joint arthritis and has obtained excellent pain relief with injections into the CMC and metacarpal phalangeal joint. She would like to proceed with an additional injection into the interphalangeal joint to the left thumb. We discussed all the options and the patient wishes to proceed with surgical intervention.
Procedure: After obtaining informed consent the patient was prepped and draped in standard surgical fashion. Esmarch was used and tourniquet inflated to 250 mm. We began with the right thumb. Incisions were reopened for placement of the previously positioned ligament reconstruction device. Dissection was carried down onto the device and this was removed without difficulty. Fluoroscopy was used intermittently to insure adequate removal of the device. It was noted that there was tissue developing along the path of the suture and upon examination under fluoroscopy it appeared that there was adequate stability of this joint and that additional ligament reconstruction device was not required. We irrigated the wound and closed the skin edges with interrupted 5-0 Monocryl dermal sutures. We dressed them with Steri-Strips gauze and an Ace wrap.
Next, we turned our attention to the left interphalangeal joint. A small amount of allograft material was mixed with the patient?s blood and a gel was formed which was injected into the interphalangeal joint space under fluoroscopic guidance. The patient tolerated the procedure well and was sent to the recovery room in good condition. The needle and instrument counts were correct at the end of the case. We discussed the findings with the family and she will follow-up in one week.
As for the allograft injection to the lt thumb I believe I would use 17999 (compared to 15777).
Here is the op report:
Indications: this patient has a previously placed right CMC joint ligament reconstruction device as well as a recent CMC arthroplasty. She has significant improvement in pain to her CMC region however there is some tightness at the CMC joint from the first to second metacarpal. On evaluation appears that her ligament reconstruction is too tight and we discussed the options of evaluating it in the operating room with removal and reevaluation as to whether the ligament reconstruction was required or if there was enough stability without the device in place. She also has a history of left thumb interphalangeal joint arthritis and has obtained excellent pain relief with injections into the CMC and metacarpal phalangeal joint. She would like to proceed with an additional injection into the interphalangeal joint to the left thumb. We discussed all the options and the patient wishes to proceed with surgical intervention.
Procedure: After obtaining informed consent the patient was prepped and draped in standard surgical fashion. Esmarch was used and tourniquet inflated to 250 mm. We began with the right thumb. Incisions were reopened for placement of the previously positioned ligament reconstruction device. Dissection was carried down onto the device and this was removed without difficulty. Fluoroscopy was used intermittently to insure adequate removal of the device. It was noted that there was tissue developing along the path of the suture and upon examination under fluoroscopy it appeared that there was adequate stability of this joint and that additional ligament reconstruction device was not required. We irrigated the wound and closed the skin edges with interrupted 5-0 Monocryl dermal sutures. We dressed them with Steri-Strips gauze and an Ace wrap.
Next, we turned our attention to the left interphalangeal joint. A small amount of allograft material was mixed with the patient?s blood and a gel was formed which was injected into the interphalangeal joint space under fluoroscopic guidance. The patient tolerated the procedure well and was sent to the recovery room in good condition. The needle and instrument counts were correct at the end of the case. We discussed the findings with the family and she will follow-up in one week.