phillirk
Guest
Should I be looking at the unlisted procedure 30999 or maybe use a fracture code 21337???
POSTOPERATIVE DIAGNOSIS: Nasal trauma and disfiguration of nose.
PROCEDURE: Elevation, left lateral cartilage, and splint application.
INDICATIONS FOR PROCEDURE: This is a young lady that was hit by a soccer ball in the nose on Saturday. She actually repositioned most of her nose herself. However, she remains with an upper lateral cartilage on the left; the lower half is indented, and putting it in place was felt prudent. Risks and benefits were discussed with the family.
TECHNIQUE: The patient was brought to the operating room and placed supine on the operating room table. A general anesthetic was provided. Following that, an Afrin pledget was placed in each side of the nose. Sterile drapes were placed. The Afrin pledgets were removed. Looking at the nose and feeling for the lower lateral fracture, a Boies elevator was used to elevate the cartilage and put it back into position. Following that, a Reuter bivalve splint was placed in the left naris to help hold that upper part in place, and then that was stitched to the septum with a 3-0 Prolene. Following that, a little bit of Gelfoam was tucked up to also help support that indentation site. The nose was then wiped with alcohol and prepped, skin cleansed (?) for the splint. The nasal splint was applied. The patient's oral cavity was suctioned and her care was returned to Anesthesia.
POSTOPERATIVE DIAGNOSIS: Nasal trauma and disfiguration of nose.
PROCEDURE: Elevation, left lateral cartilage, and splint application.
INDICATIONS FOR PROCEDURE: This is a young lady that was hit by a soccer ball in the nose on Saturday. She actually repositioned most of her nose herself. However, she remains with an upper lateral cartilage on the left; the lower half is indented, and putting it in place was felt prudent. Risks and benefits were discussed with the family.
TECHNIQUE: The patient was brought to the operating room and placed supine on the operating room table. A general anesthetic was provided. Following that, an Afrin pledget was placed in each side of the nose. Sterile drapes were placed. The Afrin pledgets were removed. Looking at the nose and feeling for the lower lateral fracture, a Boies elevator was used to elevate the cartilage and put it back into position. Following that, a Reuter bivalve splint was placed in the left naris to help hold that upper part in place, and then that was stitched to the septum with a 3-0 Prolene. Following that, a little bit of Gelfoam was tucked up to also help support that indentation site. The nose was then wiped with alcohol and prepped, skin cleansed (?) for the splint. The nasal splint was applied. The patient's oral cavity was suctioned and her care was returned to Anesthesia.