Hi list!
I am still learning surgeries and first time seeing this being done. Any suggestions on how to code would be greatly appreciated!
JNB,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Infection of soft tissue and bone RIGHT hallux (Abscess and Osteomyelitis)
POSTOPERATIVE DIAGNOSIS:
SAME
PROCEDURE:
Incision and drainage to bone RIGHT hallux
Resection of proximal phalanx bone RIGHT hallux
PATHOLOGY:
Culture - bone proximal phalanx - aerobe, anaerobe, gram stain
Histopathology - clearance margin (proximal portion of bone inked)
ESTIMATED BLOOD LOSS: minimal
MATERIALS:
3-0 Nylon
1/4" Iodoform packing
COMPLICATIONS: none
ANESTHESIA: Local Anesthetic ONLY
HEMOSTASIS: Esmark bandage ankle - well padded - 36 minutes
INJECTABLES: Marcaine 0.5% plain - 10mL
SUMMARY OF PROCEDURE:
Patient was brought into the operating room and placed on the table in the supine position. Foot was scrubbed, prepped, and draped in the usual aseptic manner after verification of site marking noted to be present on the patient. A time-out was performed with myself in the room verifying correct patient, procedure, extremity, materials present and administration of ordered antibiotics. Injection with local anesthetic performed. Well padded tourniquet was applied to the extremity.
PROCEDURE IN DETAIL:
Area of fluctuance noted to the distal aspect dorsal laterally hallux right where a longitudinal incision was made medial to lateral. There was black necrotic tissue of skin and deep fat down to the distal aspect of head of proximal phalanx. All necrotic tissue was removed. Soft bone was noted medial and lateral head Proximal phalanx thus resection of head performed and send for culture. Necrotic bone noted in medullary canal thus additional bone resected to viable appearance and proximal portion inked and sent for pathology.
Irrigation with copious amounts of normal saline 2 L with 2 units of GU irrigant performed further inspection after regloving and a sterile instrumentation revealed no further purulence necrosis or non-viability of tissues deep within the wound. Prior ulceration was excised skin was revised for appropriate closure amputation.
Dressings were applied with polysporin, adaptic, gauze, and kerlix. Tourniquet was released with prompt capillary refill time noted to the digits of the involved extremity. The patient tolerated procedure well and was transported to recovery. Following a brief postoperative course was discharged home with postoperative instructions as given preoperatively
I am still learning surgeries and first time seeing this being done. Any suggestions on how to code would be greatly appreciated!
JNB,CCS,CPC
PREOPERATIVE DIAGNOSIS:
Infection of soft tissue and bone RIGHT hallux (Abscess and Osteomyelitis)
POSTOPERATIVE DIAGNOSIS:
SAME
PROCEDURE:
Incision and drainage to bone RIGHT hallux
Resection of proximal phalanx bone RIGHT hallux
PATHOLOGY:
Culture - bone proximal phalanx - aerobe, anaerobe, gram stain
Histopathology - clearance margin (proximal portion of bone inked)
ESTIMATED BLOOD LOSS: minimal
MATERIALS:
3-0 Nylon
1/4" Iodoform packing
COMPLICATIONS: none
ANESTHESIA: Local Anesthetic ONLY
HEMOSTASIS: Esmark bandage ankle - well padded - 36 minutes
INJECTABLES: Marcaine 0.5% plain - 10mL
SUMMARY OF PROCEDURE:
Patient was brought into the operating room and placed on the table in the supine position. Foot was scrubbed, prepped, and draped in the usual aseptic manner after verification of site marking noted to be present on the patient. A time-out was performed with myself in the room verifying correct patient, procedure, extremity, materials present and administration of ordered antibiotics. Injection with local anesthetic performed. Well padded tourniquet was applied to the extremity.
PROCEDURE IN DETAIL:
Area of fluctuance noted to the distal aspect dorsal laterally hallux right where a longitudinal incision was made medial to lateral. There was black necrotic tissue of skin and deep fat down to the distal aspect of head of proximal phalanx. All necrotic tissue was removed. Soft bone was noted medial and lateral head Proximal phalanx thus resection of head performed and send for culture. Necrotic bone noted in medullary canal thus additional bone resected to viable appearance and proximal portion inked and sent for pathology.
Irrigation with copious amounts of normal saline 2 L with 2 units of GU irrigant performed further inspection after regloving and a sterile instrumentation revealed no further purulence necrosis or non-viability of tissues deep within the wound. Prior ulceration was excised skin was revised for appropriate closure amputation.
Dressings were applied with polysporin, adaptic, gauze, and kerlix. Tourniquet was released with prompt capillary refill time noted to the digits of the involved extremity. The patient tolerated procedure well and was transported to recovery. Following a brief postoperative course was discharged home with postoperative instructions as given preoperatively
