kellit21
Guru
I need help coding this surgery...
Diagnosis: Painful recalcitrant, left piriformis hip pain, unresponsive to conservative management.
Procedure: Open excisional biopsy of bursa with release of piriformis tendon.
Description of Procedure:
Through a curvilinear incision over the posterolateral aspect of the hip the skinwas incised and carried down through the subcutaneous tissue carfeully through the fascia lata and gluteus musculature. The trochanteric region of the hip was exposed. Charnley retractor was placed. Hemostasis was obtained with Bovie and Aquamantys. There was noted to be a good deal of bursal tissue about the short external rotators and this was excised and sent for pathological evaluation. The area was carefully freed. Hemostasis again obtained with the Bovie and Aquamantys. The piriformis was identified. There was noted the be some degree of fraying to the attachment with some scarring in this area. It was freed with a right angle clamp, and once free, it was then released sharply as well as the Bovie. The remaining short external rotators were left in place and did not appear to be pathalogical. No other significant pathology was noted.
Diagnosis: Painful recalcitrant, left piriformis hip pain, unresponsive to conservative management.
Procedure: Open excisional biopsy of bursa with release of piriformis tendon.
Description of Procedure:
Through a curvilinear incision over the posterolateral aspect of the hip the skinwas incised and carried down through the subcutaneous tissue carfeully through the fascia lata and gluteus musculature. The trochanteric region of the hip was exposed. Charnley retractor was placed. Hemostasis was obtained with Bovie and Aquamantys. There was noted to be a good deal of bursal tissue about the short external rotators and this was excised and sent for pathological evaluation. The area was carefully freed. Hemostasis again obtained with the Bovie and Aquamantys. The piriformis was identified. There was noted the be some degree of fraying to the attachment with some scarring in this area. It was freed with a right angle clamp, and once free, it was then released sharply as well as the Bovie. The remaining short external rotators were left in place and did not appear to be pathalogical. No other significant pathology was noted.