Hi,
Can someone help me with what CPT codes should be used for this OP note?
Thanks,
Sabrina
PREOPERATIVE DIAGNOSIS: Hammertoe 2 and 3, left foot.
POSTOPERATIVE DIAGNOSIS: Hammertoe 2 and 3, left foot.
PROCEDURE: Osteotomy, second metatarsal, left foot, skinplasty second toe, left
foot, extensor digitorum lengthening, left foot, arthrodesis proximal
interphalangeal joint, fourth toe, left foot, and extensor digitorum longus
lengthening, fourth toe, left foot.
OPERATION AND FINDINGS: The patient was taken to the operating room and placed
in the supine position on the operating table. IV sedation was provided by
anesthesia and the foot was blocked with Xylocaine 2% and Marcaine 0.5%. She
was prepped and draped in the usual sterile manner. Following prepping and
draping, an approximate 4 cm incision was made over the second metatarsal
dorsally over the distal one third. The extensor digitorum longus tendon was
lengthened at this point and a dorsal capsulotomy was performed of the second
metatarsal phalangeal joint capsule. All tight medial structures were
lengthened as well. Attention was directed to the neck of the second metatarsal
where an oblique osteotomy was performed extending from dorsal distal to plantar
proximal. A 2 mm wafer of bone was resected at the osteotomy site and the head
was reapproximated to the shaft. Using proper cannulated screw technique, a 2.5
Ortho-Pro cannulated screw was placed across the osteotomy 20 mm in length. The
head was well attached to the shaft of the second metatarsal and no motion was
noted. Site was flushed with 10% Betadine solution and deep structures closed
with 4-0 Vicryl and skin with 4-0 nylon. Attention was then directed plantar to
the base of the second toe on the left foot where a diamond shape portion of
skin was resected in such a manner that it when closed, pulled the toe in a
plantar lateral direction. This was closed with 3-0 nylon. Second toe was
noted to be in a straight anatomical position. Attention was then directed to
the fourth toe on the left foot, where a 3 cm incision was made over the dorsum
of the toe over the proximal interphalangeal joint. The extensor digitorum
longus tendon was lengthened. The proximal interphalangeal joint was resected
with a bone saw, both the head of the proximal phalanx and base of the
intermediate phalanx. The bones were then reapproximated with an 0.45 smooth
K-wire. The toe was in a straight anatomical position with no motion noted at
the arthrodesis site. Again, the site was flushed with 10% Betadine solution.
Skin closed with 4-0 nylon. Surgical sites were dressed with Betadine soaked
Adaptic, sterile 4 x 4s, 2-inch Kling and an Ace wrap. The patient tolerated
the procedure well and is returned to recovery in apparent satisfactory
condition.
Can someone help me with what CPT codes should be used for this OP note?
Thanks,
Sabrina
PREOPERATIVE DIAGNOSIS: Hammertoe 2 and 3, left foot.
POSTOPERATIVE DIAGNOSIS: Hammertoe 2 and 3, left foot.
PROCEDURE: Osteotomy, second metatarsal, left foot, skinplasty second toe, left
foot, extensor digitorum lengthening, left foot, arthrodesis proximal
interphalangeal joint, fourth toe, left foot, and extensor digitorum longus
lengthening, fourth toe, left foot.
OPERATION AND FINDINGS: The patient was taken to the operating room and placed
in the supine position on the operating table. IV sedation was provided by
anesthesia and the foot was blocked with Xylocaine 2% and Marcaine 0.5%. She
was prepped and draped in the usual sterile manner. Following prepping and
draping, an approximate 4 cm incision was made over the second metatarsal
dorsally over the distal one third. The extensor digitorum longus tendon was
lengthened at this point and a dorsal capsulotomy was performed of the second
metatarsal phalangeal joint capsule. All tight medial structures were
lengthened as well. Attention was directed to the neck of the second metatarsal
where an oblique osteotomy was performed extending from dorsal distal to plantar
proximal. A 2 mm wafer of bone was resected at the osteotomy site and the head
was reapproximated to the shaft. Using proper cannulated screw technique, a 2.5
Ortho-Pro cannulated screw was placed across the osteotomy 20 mm in length. The
head was well attached to the shaft of the second metatarsal and no motion was
noted. Site was flushed with 10% Betadine solution and deep structures closed
with 4-0 Vicryl and skin with 4-0 nylon. Attention was then directed plantar to
the base of the second toe on the left foot where a diamond shape portion of
skin was resected in such a manner that it when closed, pulled the toe in a
plantar lateral direction. This was closed with 3-0 nylon. Second toe was
noted to be in a straight anatomical position. Attention was then directed to
the fourth toe on the left foot, where a 3 cm incision was made over the dorsum
of the toe over the proximal interphalangeal joint. The extensor digitorum
longus tendon was lengthened. The proximal interphalangeal joint was resected
with a bone saw, both the head of the proximal phalanx and base of the
intermediate phalanx. The bones were then reapproximated with an 0.45 smooth
K-wire. The toe was in a straight anatomical position with no motion noted at
the arthrodesis site. Again, the site was flushed with 10% Betadine solution.
Skin closed with 4-0 nylon. Surgical sites were dressed with Betadine soaked
Adaptic, sterile 4 x 4s, 2-inch Kling and an Ace wrap. The patient tolerated
the procedure well and is returned to recovery in apparent satisfactory
condition.
