ggparker14
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Patient presents post fall from a 10 ft. height.
Findings: Right ankle: there is a fracture of the medial malleolus. The fragment is displaced inferiorly by about 7-8 mm.
There is a spiral fracture of the distal fibular diaphysis. There is no significant displacement of angulation of the fracture fragments.
There is significant soft tissue swelling about the ankle.
Right foot: There is a linear lucency extending through the plantar/posterior aspect of the calcaneus, consistent with a non-displaced fracture. The subtalar joint is not involved.
Impression:
Spiral fracture of the distal fibula.
Displaced medial malleolar fracture.
Non-displaced calcaneal fracture.
Procedure note: Splint application. A short leg posterior and stirrup type splint was applied by the nurse. Afterwards the physician adjusted the splint and performed a neurovascular exam which was wnl.
Please help with CPTs for this fracture care.
Thanks so much for any help.
Findings: Right ankle: there is a fracture of the medial malleolus. The fragment is displaced inferiorly by about 7-8 mm.
There is a spiral fracture of the distal fibular diaphysis. There is no significant displacement of angulation of the fracture fragments.
There is significant soft tissue swelling about the ankle.
Right foot: There is a linear lucency extending through the plantar/posterior aspect of the calcaneus, consistent with a non-displaced fracture. The subtalar joint is not involved.
Impression:
Spiral fracture of the distal fibula.
Displaced medial malleolar fracture.
Non-displaced calcaneal fracture.
Procedure note: Splint application. A short leg posterior and stirrup type splint was applied by the nurse. Afterwards the physician adjusted the splint and performed a neurovascular exam which was wnl.
Please help with CPTs for this fracture care.
Thanks so much for any help.