kmuth
Contributor
I need advice as I have never coded an external neurolysis. I know internal would be the primary cpt plus 64727, but would this be 64708?
PREOPERATIVE DIAGNOSIS:
Laceration to the left index finger dorsal aspect in the MP joint area.
POSTOPERATIVE DIAGNOSIS:
Laceration to the left index finger dorsal aspect in the MP joint area.
OPERATION PERFORMED:
1. Exploration to left index finger.
2. External neurolysis, dorsal sensory nerve, left index finger.
ANESTHESIA:
Bier block.
INDICATION:
Patient is a 29-year-old male, who suffered an injury to his left index finger
with a hammer. He showed me a small laceration that occurred. He was very
tender over the area where the hammer hit him and my working diagnosis was an
extensor tendon injury.
PROCEDURE IN DETAIL:
Patient was taken to the operating room on 10/29, where he was first given a
Bier block anesthetic. Next, his forearm, arm, and hand were prepped and
draped in normal sterile fashion. Next, I made a zigzag incision over the MP
joint to begin to explore the area. I could see immediately that the both
extensor tendons to the index finger were intact. However, there was heavy
amount of scar tissue surrounding the one of the dorsal sensory nerves on the
radial aspect of the MP joint. I performed an external neurolysis under 3.5
loupe magnification, removed the heavy scarified tissues, the nerve was lying
freely, removed some of the scar tissue probably from a hematoma in the area as
well. Once I checked the stability, the MP joint was stable, the collateral
ligament, sagittal band all in good position. I then irrigated the wound with
copious amounts of saline and performed a metacarpal block for postop pain
control. I then closed the incision with a running 5-0 nylon modified
horizontal mattress suture and placed him in a bulky soft bandage. He
tolerated the procedure well, was sent to the discharge area in stable
condition.
PREOPERATIVE DIAGNOSIS:
Laceration to the left index finger dorsal aspect in the MP joint area.
POSTOPERATIVE DIAGNOSIS:
Laceration to the left index finger dorsal aspect in the MP joint area.
OPERATION PERFORMED:
1. Exploration to left index finger.
2. External neurolysis, dorsal sensory nerve, left index finger.
ANESTHESIA:
Bier block.
INDICATION:
Patient is a 29-year-old male, who suffered an injury to his left index finger
with a hammer. He showed me a small laceration that occurred. He was very
tender over the area where the hammer hit him and my working diagnosis was an
extensor tendon injury.
PROCEDURE IN DETAIL:
Patient was taken to the operating room on 10/29, where he was first given a
Bier block anesthetic. Next, his forearm, arm, and hand were prepped and
draped in normal sterile fashion. Next, I made a zigzag incision over the MP
joint to begin to explore the area. I could see immediately that the both
extensor tendons to the index finger were intact. However, there was heavy
amount of scar tissue surrounding the one of the dorsal sensory nerves on the
radial aspect of the MP joint. I performed an external neurolysis under 3.5
loupe magnification, removed the heavy scarified tissues, the nerve was lying
freely, removed some of the scar tissue probably from a hematoma in the area as
well. Once I checked the stability, the MP joint was stable, the collateral
ligament, sagittal band all in good position. I then irrigated the wound with
copious amounts of saline and performed a metacarpal block for postop pain
control. I then closed the incision with a running 5-0 nylon modified
horizontal mattress suture and placed him in a bulky soft bandage. He
tolerated the procedure well, was sent to the discharge area in stable
condition.