mfranks
Contributor
I am not used to doing nerve procedure coding. Can you please take a look at this op report and tell me how you would code. The CPT's we came up with are 14040,64722 and 64999.
POSTOPERATIVE DIAGNOSES:
Right wrist radial nerve compression, superficial branch.
Right wrist painful scar.
PROCEDURES PERFORMED:
Right wrist radial nerve neurolysis and intracutaneous nerve transposition of the radial nerve, superficial branch.
Right wrist scar revision.
Adipose tissue flap development and advancement for nerve coverage.
ANESTHESIA: General
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. After general anesthesia was ensured, the patient's right upper extremity was prepped with chlorhexidine gluconate. Sterile drapings were placed in standard manner. The tourniquet was inflated to 100 mm over systolic pressure.
The patient had two previous surgeries on the right wrist dealing with the first extensor compartment region and the radial nerve, and she has shown lack of function of the radial nerve with extreme pain. The scar had widened and was approximately 8 cm long and 1.5 wide. Because of exploration and the planned treatment of this nerve, I elected to excise the scar, which was painful and widened. The scar was completely excised then.
Then, I approached the radial nerve in the proximal portion of the wound and the incision was extended approximately 3 cm. The radial nerve was found to be severely compressed with an hourglass appearance at its exit from unde the tender insertion of the brachial radialis tendon.
A portion of the tendon and all the surrounding tissue compressing the nerve was completely excised. The nerve was dissected distally. There was severe scarring at the deep surface of the nerve and surrounding the branches going to the radial styloid region, and complete neurolysis was carried out. The patient had a previous surgery for de Quervain's tenosynovitis done twice, and the scar tissue was quite severe in this region near the periosteum and in the tendon. It was evident that if the nerve was left just neurolyzed scar tissue would in fact recur with compromising nerve function again. Therefore, a well-defined flap was created and advanced dorsally, containing adipose tissue, and this flap of adipose tissue from the dorsal side was still left attached to the subcutaneous tissue, but advanced under the radial nerve to elevate the nerve approximately 6 mm from any scar formation in the periosteum and tendon sheath structures. This was secured with Vicryl sutures so the nerve will remain in the subcutaneous tissue, minimizing scar potential for this. The nerve, although visible, had severe scarring and hyperemic reaction to neurolysis, and did have significant visible atrophy. At this time, because the nerve was in continuity and there was potential for healing, I did not feel it was appropriate to proceed with a neurotomy and all the potential complications from this.
The wound was irrigated. Hemostasis was carefully controlled with electrocautery and pressure. Then, the wound was closed with 4-0 Vicryl subcutaneous sutures and 5-0 nylon for the skin. The tourniquet had been deflated prior t o closure for hemostasis control. Xeroform gauze, Kerlix, and a thumb spica forearm-based splint with a three-inch Ace were utilized as a dressing. The patient was sent to postanesthesia recovery in stable condition. There were no complications.
NOTE: The subcutaneous tissue flap developed and advanced under the nerve was 8 cm long x 2 cm wide.
POSTOPERATIVE DIAGNOSES:
Right wrist radial nerve compression, superficial branch.
Right wrist painful scar.
PROCEDURES PERFORMED:
Right wrist radial nerve neurolysis and intracutaneous nerve transposition of the radial nerve, superficial branch.
Right wrist scar revision.
Adipose tissue flap development and advancement for nerve coverage.
ANESTHESIA: General
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in supine position. After general anesthesia was ensured, the patient's right upper extremity was prepped with chlorhexidine gluconate. Sterile drapings were placed in standard manner. The tourniquet was inflated to 100 mm over systolic pressure.
The patient had two previous surgeries on the right wrist dealing with the first extensor compartment region and the radial nerve, and she has shown lack of function of the radial nerve with extreme pain. The scar had widened and was approximately 8 cm long and 1.5 wide. Because of exploration and the planned treatment of this nerve, I elected to excise the scar, which was painful and widened. The scar was completely excised then.
Then, I approached the radial nerve in the proximal portion of the wound and the incision was extended approximately 3 cm. The radial nerve was found to be severely compressed with an hourglass appearance at its exit from unde the tender insertion of the brachial radialis tendon.
A portion of the tendon and all the surrounding tissue compressing the nerve was completely excised. The nerve was dissected distally. There was severe scarring at the deep surface of the nerve and surrounding the branches going to the radial styloid region, and complete neurolysis was carried out. The patient had a previous surgery for de Quervain's tenosynovitis done twice, and the scar tissue was quite severe in this region near the periosteum and in the tendon. It was evident that if the nerve was left just neurolyzed scar tissue would in fact recur with compromising nerve function again. Therefore, a well-defined flap was created and advanced dorsally, containing adipose tissue, and this flap of adipose tissue from the dorsal side was still left attached to the subcutaneous tissue, but advanced under the radial nerve to elevate the nerve approximately 6 mm from any scar formation in the periosteum and tendon sheath structures. This was secured with Vicryl sutures so the nerve will remain in the subcutaneous tissue, minimizing scar potential for this. The nerve, although visible, had severe scarring and hyperemic reaction to neurolysis, and did have significant visible atrophy. At this time, because the nerve was in continuity and there was potential for healing, I did not feel it was appropriate to proceed with a neurotomy and all the potential complications from this.
The wound was irrigated. Hemostasis was carefully controlled with electrocautery and pressure. Then, the wound was closed with 4-0 Vicryl subcutaneous sutures and 5-0 nylon for the skin. The tourniquet had been deflated prior t o closure for hemostasis control. Xeroform gauze, Kerlix, and a thumb spica forearm-based splint with a three-inch Ace were utilized as a dressing. The patient was sent to postanesthesia recovery in stable condition. There were no complications.
NOTE: The subcutaneous tissue flap developed and advanced under the nerve was 8 cm long x 2 cm wide.