jdibble
True Blue
I need some opinions on how to code this OP report. The patient was having pain from the screws inserted so our doctor took them out and then replaced them again with smaller screws. What CPT code(s) would you use?
Operative Report
PREOPERATIVE DIAGNOSIS: Painful hardware.
POSTOPERATIVE DIAGNOSIS: Painful hardware.
ANESTHESIA: General administered by Dr. Martinez.
PROCEDURE: Exchange of 2 screws of the volar plate of the right forearm.
PROCEDURE WAS AS FOLLOWS: After the patient was anesthetized and draped in the appropriate fashion, a time-out was called to verify the patient, the laterality, the fact that he was given IV, the fact that he is on no beta-blockers, etc. At this time, after having the tourniquet elevated approximately 250 mmHg, the screws were palpated on the dorsal aspect of the forearm, and the incision was made volarly through the old scar. This was taken down onto the brachioradialis and the flexors of the hand with blunt dissection. The plate was easily identified and 2 screws were removed without any difficulty. One was locking and one was a regular cortical screw. They were removed and measured each being at least 4 mm smaller than the ones that were in there. Once the screws were inserted, x-rays were done to verify that they were not too prominent. This being the situation, the wound was copiously irrigated and closed using 0-Vicryl for deep, 2-0 subcutaneously and a skin gun for the skin. After cleansing the wound, a sterile bulky dressing was applied, anesthesia at this time was reversed. Patient tolerated the procedure well and left the OR in good condition.
Thank you everyone for your help!
Operative Report
PREOPERATIVE DIAGNOSIS: Painful hardware.
POSTOPERATIVE DIAGNOSIS: Painful hardware.
ANESTHESIA: General administered by Dr. Martinez.
PROCEDURE: Exchange of 2 screws of the volar plate of the right forearm.
PROCEDURE WAS AS FOLLOWS: After the patient was anesthetized and draped in the appropriate fashion, a time-out was called to verify the patient, the laterality, the fact that he was given IV, the fact that he is on no beta-blockers, etc. At this time, after having the tourniquet elevated approximately 250 mmHg, the screws were palpated on the dorsal aspect of the forearm, and the incision was made volarly through the old scar. This was taken down onto the brachioradialis and the flexors of the hand with blunt dissection. The plate was easily identified and 2 screws were removed without any difficulty. One was locking and one was a regular cortical screw. They were removed and measured each being at least 4 mm smaller than the ones that were in there. Once the screws were inserted, x-rays were done to verify that they were not too prominent. This being the situation, the wound was copiously irrigated and closed using 0-Vicryl for deep, 2-0 subcutaneously and a skin gun for the skin. After cleansing the wound, a sterile bulky dressing was applied, anesthesia at this time was reversed. Patient tolerated the procedure well and left the OR in good condition.
Thank you everyone for your help!