I new to the ASC and I have a question on the CPT codes that would be used for this procedure.
PREOPERATIVE DIAGNOSIS
Right foot first metatarsal osteomyelitis.
POSTOPERATIVE DIAGNOSIS
Right foot first metatarsal osteomyelitis.
OPERATION PERFORMED
Right foot first ray amputation with sesamoid resection.
ANESTHESIA
MAC plus local consisting of 5 mL of 0.25% Marcaine without epinephrine mixed
with 5 mL of 2% lidocaine without epinephrine.
COMPLICATIONS
None.
SPECIMEN(S)
Distal right first metatarsal with sesamoid bone.
DESCRIPTION OF PROCEDURE IN DETAIL
After identification of the patient by name and identification tag in the
preoperative holding area, the right foot was marked as the correct operative
site. The patient was brought to the operating room and placed on the
operating table in the supine position. Intravenous sedation was provided by
the anesthesia service. A right foot first ray block was performed with the
above-mentioned anesthetic. The right foot was prepped and draped in the
standard surgical fashion. No tourniquet was utilized.
The surgery was begun by completely excising the open sinus tract at the end
of the right foot at the previous right big toe amputation site. The surgical
incision was then extended proximally over the medial aspect of the first
metatarsal. This was subperiosteally exposed and utilizing an oscillating
saw, the distal first metatarsal shaft was resected. The soft tissue was then
sharply debrided with a #15 blade scalpel and the sesamoid bones were also
sharply resected as well.
Hemostasis was obtained with Bovie cautery and the wound was copiously
irrigated with normal saline. Closure was obtained utilizing PDS suture and
nylon suture. A soft bulky dressing was applied to the right foot and the
patient was transferred to the hospital stretcher and taken to the recovery
room in stable condition.
Thanks for the help!!
PREOPERATIVE DIAGNOSIS
Right foot first metatarsal osteomyelitis.
POSTOPERATIVE DIAGNOSIS
Right foot first metatarsal osteomyelitis.
OPERATION PERFORMED
Right foot first ray amputation with sesamoid resection.
ANESTHESIA
MAC plus local consisting of 5 mL of 0.25% Marcaine without epinephrine mixed
with 5 mL of 2% lidocaine without epinephrine.
COMPLICATIONS
None.
SPECIMEN(S)
Distal right first metatarsal with sesamoid bone.
DESCRIPTION OF PROCEDURE IN DETAIL
After identification of the patient by name and identification tag in the
preoperative holding area, the right foot was marked as the correct operative
site. The patient was brought to the operating room and placed on the
operating table in the supine position. Intravenous sedation was provided by
the anesthesia service. A right foot first ray block was performed with the
above-mentioned anesthetic. The right foot was prepped and draped in the
standard surgical fashion. No tourniquet was utilized.
The surgery was begun by completely excising the open sinus tract at the end
of the right foot at the previous right big toe amputation site. The surgical
incision was then extended proximally over the medial aspect of the first
metatarsal. This was subperiosteally exposed and utilizing an oscillating
saw, the distal first metatarsal shaft was resected. The soft tissue was then
sharply debrided with a #15 blade scalpel and the sesamoid bones were also
sharply resected as well.
Hemostasis was obtained with Bovie cautery and the wound was copiously
irrigated with normal saline. Closure was obtained utilizing PDS suture and
nylon suture. A soft bulky dressing was applied to the right foot and the
patient was transferred to the hospital stretcher and taken to the recovery
room in stable condition.
Thanks for the help!!