I need help coding this please!!! I don't know if I should just code the removal of hardware or if I should also code for the K-wire that he placed? Here is the op note:
POSTOPERATIVE DIAGNOSES: 1. Exposed hardware medial malleolus.
2. Status post trimalleolar fracture, left.
PROCEDURES PERFORMED: 1. Removal of hardware.
2. Percutaneous K-wire fixation to allow
additional stability to medial malleolus
a 75-year-old female who had a fall and was
admitted to the hospital a few months back. The patient was admitted and was consulted by partner to
take care of the ankle fracture which we did. Intraoperative procedure was trimalleolar ankle fracture.
The patient has severe osteoporosis, is a smoker. During the course of the primary procedure, retention of
the hardware was notably questionable. The FibuLock nail was stable in the fibula. The medial malleolar
screws were applied, but did have some looseness. Attempt to put a transsyndesmotic screw in was
failed as well as a TightRope. Both devices provide no retention and the TightRope pulled out during
tightening indicating the patient's severity of her osteoporosis. She was stabilized through the repair, kept
in nonweightbearing status and has been. She was sent home eventually where she was noncompliant on
the surgery, displaced the medial mal a little bit separating the screw, creating additional trauma to the skin
on the medial side of the ankle thus causing a large eschar. The eschar loosened and exposed a portion of
the wound. The patient got cutaneous infection which was cleared in responsive to oral antibiotics,
however, the screw exposed leading to procedure today. Discussed at length to the family that if she does
not comply, the infection risk is very high with open lesion and likely delayed and/or nonhealing medial
malleolus. Based on x-ray, the bone was displaced slightly on her ambulatory process, however, did not
feel the necessity to go back in and attempt revision due to her compliance issues and her smoking. The
procedure current was booked as hardware removal and additional support as needed. Discussed with the
patient's husband that we would replace the screw with percutaneous K-wire if needed for additional
stability that did occur during the case and however no evidence of gross infection or purulence was noted
today, I will detail that in the description.
PROCEDURE IN DETAIL: The patient was identified and placed on the treatment table in the supine
position. Following IV sedation, local anesthesia obtained about the patient's left foot and ankle with 10 cc
of 1% plain Xylocaine. I was able to expose visibly to the distal portion of the open wound. Culture was
taken prior to prep. Hardware was removed after the prep. Good bleeding surface was noted to the site.
The eschar had loose edges and was trimmed. Good bleeding surface was noted around the area. Live
x-ray was taken. Range of motion on the table was good. There was minor mobility, actually less than
expected of the medial mal fragment, however, still felt we need to retain that. A percutaneous wire was
then placed distal to the wound through good skin into the medial malleolus for retention. The wire was
cut and bent extrinsically and padded. Following the procedure, Xeroform, 4x4s, Kerlix and Ace bandages
were applied. The patient was discharged from the treatment room with vital signs stable and vascular
status intact where the strict written oral postoperative instructions were made, nonweightbearing or she
could utilize a walker with her boot for heel touch for transfer weight and to utilize for a transfer to the
restroom and in and out of a car for office visits. The patient will follow up in one weeks time for
evaluation.
Any help will be greatly appreciated! Thanks in advance!!!!!
POSTOPERATIVE DIAGNOSES: 1. Exposed hardware medial malleolus.
2. Status post trimalleolar fracture, left.
PROCEDURES PERFORMED: 1. Removal of hardware.
2. Percutaneous K-wire fixation to allow
additional stability to medial malleolus
a 75-year-old female who had a fall and was
admitted to the hospital a few months back. The patient was admitted and was consulted by partner to
take care of the ankle fracture which we did. Intraoperative procedure was trimalleolar ankle fracture.
The patient has severe osteoporosis, is a smoker. During the course of the primary procedure, retention of
the hardware was notably questionable. The FibuLock nail was stable in the fibula. The medial malleolar
screws were applied, but did have some looseness. Attempt to put a transsyndesmotic screw in was
failed as well as a TightRope. Both devices provide no retention and the TightRope pulled out during
tightening indicating the patient's severity of her osteoporosis. She was stabilized through the repair, kept
in nonweightbearing status and has been. She was sent home eventually where she was noncompliant on
the surgery, displaced the medial mal a little bit separating the screw, creating additional trauma to the skin
on the medial side of the ankle thus causing a large eschar. The eschar loosened and exposed a portion of
the wound. The patient got cutaneous infection which was cleared in responsive to oral antibiotics,
however, the screw exposed leading to procedure today. Discussed at length to the family that if she does
not comply, the infection risk is very high with open lesion and likely delayed and/or nonhealing medial
malleolus. Based on x-ray, the bone was displaced slightly on her ambulatory process, however, did not
feel the necessity to go back in and attempt revision due to her compliance issues and her smoking. The
procedure current was booked as hardware removal and additional support as needed. Discussed with the
patient's husband that we would replace the screw with percutaneous K-wire if needed for additional
stability that did occur during the case and however no evidence of gross infection or purulence was noted
today, I will detail that in the description.
PROCEDURE IN DETAIL: The patient was identified and placed on the treatment table in the supine
position. Following IV sedation, local anesthesia obtained about the patient's left foot and ankle with 10 cc
of 1% plain Xylocaine. I was able to expose visibly to the distal portion of the open wound. Culture was
taken prior to prep. Hardware was removed after the prep. Good bleeding surface was noted to the site.
The eschar had loose edges and was trimmed. Good bleeding surface was noted around the area. Live
x-ray was taken. Range of motion on the table was good. There was minor mobility, actually less than
expected of the medial mal fragment, however, still felt we need to retain that. A percutaneous wire was
then placed distal to the wound through good skin into the medial malleolus for retention. The wire was
cut and bent extrinsically and padded. Following the procedure, Xeroform, 4x4s, Kerlix and Ace bandages
were applied. The patient was discharged from the treatment room with vital signs stable and vascular
status intact where the strict written oral postoperative instructions were made, nonweightbearing or she
could utilize a walker with her boot for heel touch for transfer weight and to utilize for a transfer to the
restroom and in and out of a car for office visits. The patient will follow up in one weeks time for
evaluation.
Any help will be greatly appreciated! Thanks in advance!!!!!