MLamKuo18
New
I have a op report that reads as follows:
Procedures performed are Left small finger Dupuytren's excision from finger and palm and Left small finger Dupuytren's excision from the adbuctor digiti minimi.
Procedure in detail: The patient was identified in the preoperative holding area and the correct operative site was marked. She was brought back to the operating room, placed in the supine position with the left arm out on the arm table. Left arm was prepped and draped in a standard sterile fashion. Time-out was performed, confirming the patient's name, side and operation to be performed. Esmarch was used for exsanguination and the tourniquet was inflated. Total tourniquet time was 31 minutes. I began with Bruner type incision in the small finger extending from the crease of the proximal interphalangeal joint and going proximally about a third of the way up to palm. Dissection was taken down carefully to expose the underlying Dupuytren's cords. I dissected on the radial and ulnar sides of the cord for the small finger and identified the neurovascular bundles. These were protected throughout the case with Ragnell retractors. I found the proximal extent of the Dupuytren's cord and transected it. I then held onto the Dupuytren's cord with an Allis clamp and traced it distally, again taking care to protect the neurovascular bundles noted on the ulnar side of the digit. Once I had reached its distal extent, it was transected and removed. After this cord was removed, the MCP and PIP joints were able to be fully extended. I then turned my attention to the Dupuytren's cord that was adherent to the abductor digiti minimi. I isolated the cord from the underlying soft tissues and protected again the neurovascular bundles with Ragnell retractors. We found it and fixed that proximally and transected it and then traced the cord distally to the area of the insertion at the abductor digiti minimi tendon. It was then transected. The wound was then copiously irrigated and closed with interrupted nylon stitches. The wounds were dressed with Xeroform and gauze and she was placed into a very well padded ulnar gutter splint with the fingers in extension. Once the tourniquet was deflated, all fingers were pink and well perfused. She was then aroused from general anesthesia and taken to the PACU without event.
I would normally code 26123-F4 for the one, but would there be any additional code?
Procedures performed are Left small finger Dupuytren's excision from finger and palm and Left small finger Dupuytren's excision from the adbuctor digiti minimi.
Procedure in detail: The patient was identified in the preoperative holding area and the correct operative site was marked. She was brought back to the operating room, placed in the supine position with the left arm out on the arm table. Left arm was prepped and draped in a standard sterile fashion. Time-out was performed, confirming the patient's name, side and operation to be performed. Esmarch was used for exsanguination and the tourniquet was inflated. Total tourniquet time was 31 minutes. I began with Bruner type incision in the small finger extending from the crease of the proximal interphalangeal joint and going proximally about a third of the way up to palm. Dissection was taken down carefully to expose the underlying Dupuytren's cords. I dissected on the radial and ulnar sides of the cord for the small finger and identified the neurovascular bundles. These were protected throughout the case with Ragnell retractors. I found the proximal extent of the Dupuytren's cord and transected it. I then held onto the Dupuytren's cord with an Allis clamp and traced it distally, again taking care to protect the neurovascular bundles noted on the ulnar side of the digit. Once I had reached its distal extent, it was transected and removed. After this cord was removed, the MCP and PIP joints were able to be fully extended. I then turned my attention to the Dupuytren's cord that was adherent to the abductor digiti minimi. I isolated the cord from the underlying soft tissues and protected again the neurovascular bundles with Ragnell retractors. We found it and fixed that proximally and transected it and then traced the cord distally to the area of the insertion at the abductor digiti minimi tendon. It was then transected. The wound was then copiously irrigated and closed with interrupted nylon stitches. The wounds were dressed with Xeroform and gauze and she was placed into a very well padded ulnar gutter splint with the fingers in extension. Once the tourniquet was deflated, all fingers were pink and well perfused. She was then aroused from general anesthesia and taken to the PACU without event.
I would normally code 26123-F4 for the one, but would there be any additional code?