cclarson
Guru
I'm needing help understanding how to code the procedures completed, I'm not familiar with some of the procedures done. I know some will bundle into others, but it's a little hard to grasp. Any help or advice would be deeply appreciated.
Here is the report:
POSTOPERATIVE DIAGNOSES:
1. Left clenched fist deformity.
2. Left elbow flexion contracture.
OPERATION PERFORMED:
1. Flexor digitorum superficialis to flexor digitorum profundus tendon transfer left hand. (26485?)
2. Lengthening left biceps tendon. (24305)
3. Release of left brachioradialis. Unlisted?
4. Left elbow capsulotomy. Unlisted?
5. Flexor digitorum longus Z-lengthening. (26478? Would this be bundled?)
6. Left flexor carpi radialis tenotomy. 25290?
7. Left flexor carpi ulnaris tenotomy. 25290?
DESCRIPTION OF PROCEDURE:
The patient was met in the holding area. The surgical site was marked and confirmed. The patient was then transported to the OR and remained in the supine position on the gurney. The bed was rotated to allow better access to the left upper extremity. Hand table was attached to the left side of the gurney and upper arm tourniquet was applied. She then underwent prep and drape. After prep and drape, time out was performed. After routine time out, we proceeded with the procedure.
I exsanguinated the extremity with an Esmarch bandage and inflated the tourniquet to 250 mmHg. I then made a transverse incision within the antecubital fossa and brought the incision proximally. Sharp dissection through the skin was followed by blunt dissection. I exposed the biceps tendon with some difficulty given the amount of contracture. Her elbow had a flexion contracture about 100 degrees. I did a Z-step cut incision in the left biceps performing a Z-lengthening of the biceps. I gained very little length.
I then decided at this time given her adduction contracture of the left shoulder that it would benefit me more to attempt to a lateral approach to her elbow and perform a lateral column procedure.
I then made a lateral incision on the elbow along the lateral condyle extending down to the radiocapitellar joint. Sharp dissection through skin was followed by blunt dissection. I exposed the lateral condyle and then elevated the brachioradialis off of the distal humerus. There was significant contracture of the brachioradialis. I continued to release the brachioradialis and performed incision of the fascia to help open up the elbow. I continued across the anterior aspect of the humerus elevating the musculature off of the anterior aspect humerus. I opened the capsule and performed capsulotomy of the ulnohumeral and radiocapitellar joints. I released a portion of the lateral collateral ligament sharply and then continued my dissection with a wooden handled elevator across the distal humerus elevating the musculature off of the distal humerus and releasing her elbow contracture. I was able to finally extend her elbow fully after releasing the last remnants of her contracture. I then irrigated the wound thoroughly and closed the incisions using subQ Monocryl and infiltrated the wound with 20 mL of local anesthetic.
I then prepped the volar aspect of the forearm again and changed gloves due to some concern about possible incomplete prepping of the antecubital fossa due to the severity of the contracture. Examination of her foremen and hand showed that she had developed a pronation contracture and was unable to supinate her forearm past neutral but had full pronation. I therefore pronated her forearm fully and flexed the elbow. Since we were unable to pull her arm away from her side given her shoulder contracture, I made an incision down the volar aspect of her forearm down for about 10 to 12 cm eExtending my incision down into the carpal tunnel. I released he carpal tunnel. I then performed a tenotomy of the palmaris tendon, followed by tenotomies of the FCR and FCU tendons. After release of the FCR and FCU I found and isolated the median nerve and ulnar nerve. I visualized the FDS and FDP. I isolated FDS and FDP. I placed a 2-0 Ethibond across the FDS tendon just proximal to the carpal tunnel. I then transected the FDS tendon, gained some extension of the digits with this transaction. I then turned my attention to the FDP tendons. Again, I made I sutured the tendons together using 2-0 Ethibond proximally almost to the musculotendinous junction. Several sutures were placed across the FDP tendons to create a single tendon. I then transected the tendon proximally, proximal to the sutures. I was then able to open her hand. There were flexion contractures of the PIP joints of the long and ring finger. I extended the digits as far as possible and was able to open her hand to allow for cleaning. I then repaired the FDS and FDP tendons placing two stranded Kessler sutures using 2-0 Ethibond into each of the tendons. I then finished my repair with an epitendinous repair using 2-0 Ethibond.
When I was satisfied with my repair and was able to fully extend the digits, I noticed that there was some increased tension of the thumb. I performed a Z-lengthening of the thumb FPL. I also incised the fascia of the pronator to reduce the tension on the forearm.
I irrigated the wound thoroughly. I then closed the incision using subQ Monocryl. I then infiltrated the wound with local anesthetic. I applied Xeroform to the incisions, followed sterile 4x4s, sterile Webril, and a long arm splint of fiberglass with the elbow extended to about 45 degrees and the hand as open as far as it would go. The splint was then overwrapped with Ace bandage. The patient was awaken, extubated, and taken recovery room.
Here is the report:
POSTOPERATIVE DIAGNOSES:
1. Left clenched fist deformity.
2. Left elbow flexion contracture.
OPERATION PERFORMED:
1. Flexor digitorum superficialis to flexor digitorum profundus tendon transfer left hand. (26485?)
2. Lengthening left biceps tendon. (24305)
3. Release of left brachioradialis. Unlisted?
4. Left elbow capsulotomy. Unlisted?
5. Flexor digitorum longus Z-lengthening. (26478? Would this be bundled?)
6. Left flexor carpi radialis tenotomy. 25290?
7. Left flexor carpi ulnaris tenotomy. 25290?
DESCRIPTION OF PROCEDURE:
The patient was met in the holding area. The surgical site was marked and confirmed. The patient was then transported to the OR and remained in the supine position on the gurney. The bed was rotated to allow better access to the left upper extremity. Hand table was attached to the left side of the gurney and upper arm tourniquet was applied. She then underwent prep and drape. After prep and drape, time out was performed. After routine time out, we proceeded with the procedure.
I exsanguinated the extremity with an Esmarch bandage and inflated the tourniquet to 250 mmHg. I then made a transverse incision within the antecubital fossa and brought the incision proximally. Sharp dissection through the skin was followed by blunt dissection. I exposed the biceps tendon with some difficulty given the amount of contracture. Her elbow had a flexion contracture about 100 degrees. I did a Z-step cut incision in the left biceps performing a Z-lengthening of the biceps. I gained very little length.
I then decided at this time given her adduction contracture of the left shoulder that it would benefit me more to attempt to a lateral approach to her elbow and perform a lateral column procedure.
I then made a lateral incision on the elbow along the lateral condyle extending down to the radiocapitellar joint. Sharp dissection through skin was followed by blunt dissection. I exposed the lateral condyle and then elevated the brachioradialis off of the distal humerus. There was significant contracture of the brachioradialis. I continued to release the brachioradialis and performed incision of the fascia to help open up the elbow. I continued across the anterior aspect of the humerus elevating the musculature off of the anterior aspect humerus. I opened the capsule and performed capsulotomy of the ulnohumeral and radiocapitellar joints. I released a portion of the lateral collateral ligament sharply and then continued my dissection with a wooden handled elevator across the distal humerus elevating the musculature off of the distal humerus and releasing her elbow contracture. I was able to finally extend her elbow fully after releasing the last remnants of her contracture. I then irrigated the wound thoroughly and closed the incisions using subQ Monocryl and infiltrated the wound with 20 mL of local anesthetic.
I then prepped the volar aspect of the forearm again and changed gloves due to some concern about possible incomplete prepping of the antecubital fossa due to the severity of the contracture. Examination of her foremen and hand showed that she had developed a pronation contracture and was unable to supinate her forearm past neutral but had full pronation. I therefore pronated her forearm fully and flexed the elbow. Since we were unable to pull her arm away from her side given her shoulder contracture, I made an incision down the volar aspect of her forearm down for about 10 to 12 cm eExtending my incision down into the carpal tunnel. I released he carpal tunnel. I then performed a tenotomy of the palmaris tendon, followed by tenotomies of the FCR and FCU tendons. After release of the FCR and FCU I found and isolated the median nerve and ulnar nerve. I visualized the FDS and FDP. I isolated FDS and FDP. I placed a 2-0 Ethibond across the FDS tendon just proximal to the carpal tunnel. I then transected the FDS tendon, gained some extension of the digits with this transaction. I then turned my attention to the FDP tendons. Again, I made I sutured the tendons together using 2-0 Ethibond proximally almost to the musculotendinous junction. Several sutures were placed across the FDP tendons to create a single tendon. I then transected the tendon proximally, proximal to the sutures. I was then able to open her hand. There were flexion contractures of the PIP joints of the long and ring finger. I extended the digits as far as possible and was able to open her hand to allow for cleaning. I then repaired the FDS and FDP tendons placing two stranded Kessler sutures using 2-0 Ethibond into each of the tendons. I then finished my repair with an epitendinous repair using 2-0 Ethibond.
When I was satisfied with my repair and was able to fully extend the digits, I noticed that there was some increased tension of the thumb. I performed a Z-lengthening of the thumb FPL. I also incised the fascia of the pronator to reduce the tension on the forearm.
I irrigated the wound thoroughly. I then closed the incision using subQ Monocryl. I then infiltrated the wound with local anesthetic. I applied Xeroform to the incisions, followed sterile 4x4s, sterile Webril, and a long arm splint of fiberglass with the elbow extended to about 45 degrees and the hand as open as far as it would go. The splint was then overwrapped with Ace bandage. The patient was awaken, extubated, and taken recovery room.