mfranks
Contributor
Please see the attached op report. Dr is stating that this should be coded as a 25116 x3. I believe that it is a 25118 x3. Any opinions?
OPERATIVE FINDINGS AND PROCEDURE: After informed consent was obtained, the patient was brought to the operating room and placed in supine position. I.V. sedation was administered. The patient's left upper extremity was prepped and draped in the usual sterile fashion. The left upper extremity was exsanguinated and the tourniquet inflated.
An oblique incision was made over the dorsal distal left wrist. Dissection was carefully deepened through the subcutaneous tissues. The extensor retinaculum was identified. The various extensor compartments were inspected. The second, fourth, and sixth compartments appeared to have significant tenosynovitis. These extensor compartments were each individually debrided. The wrist was tested through its range of motion. The was no ECU subluxation. For this reason, although the ECU tendon was in a subluxed position, a stabilization procedure was not performed
The wound was copiously irrigated with saline solution. The skin was reapproximated using 5-0 Monocryl suture in a subcuticular fashion. The tourniquet was released with immediate reperfusion in the hand and digits. A sterile dressing and a well-padded splint were applied. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
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OPERATIVE FINDINGS AND PROCEDURE: After informed consent was obtained, the patient was brought to the operating room and placed in supine position. I.V. sedation was administered. The patient's left upper extremity was prepped and draped in the usual sterile fashion. The left upper extremity was exsanguinated and the tourniquet inflated.
An oblique incision was made over the dorsal distal left wrist. Dissection was carefully deepened through the subcutaneous tissues. The extensor retinaculum was identified. The various extensor compartments were inspected. The second, fourth, and sixth compartments appeared to have significant tenosynovitis. These extensor compartments were each individually debrided. The wrist was tested through its range of motion. The was no ECU subluxation. For this reason, although the ECU tendon was in a subluxed position, a stabilization procedure was not performed
The wound was copiously irrigated with saline solution. The skin was reapproximated using 5-0 Monocryl suture in a subcuticular fashion. The tourniquet was released with immediate reperfusion in the hand and digits. A sterile dressing and a well-padded splint were applied. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
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