Sara82
Guru
Dr want to code 28289, hoever the patient does not have a hallux rigidus. Copy of reort below. Any suggestions as to what other code should be used?
POSTOPERATIVE DIAGNOSIS:
Left foot with chronic drainage from dorsomedial wound, left forefoot, at the
level of the metatarsophalangeal joint.
PRINCIPAL PROCEDURES:
1. Left foot excision of chronic draining sinus from the dorsomedial aspect of
the great toe.
2. Dorsal cheilectomy of the first metatarsophalangeal joint.
3. Irrigation debridement of skin and subcutaneous tissue.
INDICATIONS FOR SURGERY:
The patient was brought for the above procedures. The
patient was brought to the operating room and placed in the supine position.
Following administration of anesthesia, the patient was prepped and draped in
usual sterile fashion. The patient received perioperative antibiotics. We
began by making an approximately 6 cm incision overlying the dorsum of the left
foot encompassing the round sinus that was overlying the dorsomedial aspect of
the great toe at the level of the first metatarsophalangeal joint. We ellipsed
out that area and then we removed that sinus tract which we tracked down into
the skin and subcutaneous tissue only. There did not appear to be any deeper
tract with this. We sent this off for pathology review. We debrided the skin
and subcutaneous tissue, devitalized poor tissue. We then opened due to formal
open arthrotomy over the dorsum of the great toe MTP joint and there was an
egress of normal-appearing tissue. We identified very large osteophytes,
especially one on the dorsomedial aspect of the great toe which appeared
overlying the area of the chronic sinus formation. Using a sagittal saw and
using a rongeur, we performed a cheilectomy of the large spurring on the dorsum
of the foot. We did this also on the phalangeal side of the MTP joint. Once
we had completed this, the rest of the bone appeared in good condition. The
cartilage was in good condition. There were no loose bodies present. There
was certainly no pus present.
POSTOPERATIVE DIAGNOSIS:
Left foot with chronic drainage from dorsomedial wound, left forefoot, at the
level of the metatarsophalangeal joint.
PRINCIPAL PROCEDURES:
1. Left foot excision of chronic draining sinus from the dorsomedial aspect of
the great toe.
2. Dorsal cheilectomy of the first metatarsophalangeal joint.
3. Irrigation debridement of skin and subcutaneous tissue.
INDICATIONS FOR SURGERY:
The patient was brought for the above procedures. The
patient was brought to the operating room and placed in the supine position.
Following administration of anesthesia, the patient was prepped and draped in
usual sterile fashion. The patient received perioperative antibiotics. We
began by making an approximately 6 cm incision overlying the dorsum of the left
foot encompassing the round sinus that was overlying the dorsomedial aspect of
the great toe at the level of the first metatarsophalangeal joint. We ellipsed
out that area and then we removed that sinus tract which we tracked down into
the skin and subcutaneous tissue only. There did not appear to be any deeper
tract with this. We sent this off for pathology review. We debrided the skin
and subcutaneous tissue, devitalized poor tissue. We then opened due to formal
open arthrotomy over the dorsum of the great toe MTP joint and there was an
egress of normal-appearing tissue. We identified very large osteophytes,
especially one on the dorsomedial aspect of the great toe which appeared
overlying the area of the chronic sinus formation. Using a sagittal saw and
using a rongeur, we performed a cheilectomy of the large spurring on the dorsum
of the foot. We did this also on the phalangeal side of the MTP joint. Once
we had completed this, the rest of the bone appeared in good condition. The
cartilage was in good condition. There were no loose bodies present. There
was certainly no pus present.