Can someone help me code this and highlight the documentation of each procedure, I am new to this type of coding and unsure of myself
PROCEDURE PERFORMED:
1. Akin osteotomy, right foot.
2. Lateral release with freeing of the sesamoids, right
foot.
3. V-Y tenoplasty, right foot.
4. Application of graft, right foot..
5. Extensor tenotomy 2nd MPJ, right foot.
6. First metatarsal osteotomy with screw fixation, left
foot.
PROCEDURE IN DETAIL: After reviewing patient history and
physical and noting no significant _____, the patient was
brought to operating room, placed on the operating table in
supine position. The surgeon, assistant, anesthesiologist,
nurses a timeout was called to verify the patient's name,
procedure to be performed, _____ performed. All present were
in agreement. Following adequate IV sedation, a local
anesthetic block was administered to the patient's right and
left foot in standard Mayo type fashion utilizing a total of
20 mL of 1% lidocaine plain. The patient's foot was then
scrubbed, prepped and draped in usual aseptic manner.
Attention was then directed to the patient's right foot.
Utilizing Esmarch bandage, the patient's right foot was
exsanguinated and pneumatic ankle tourniquet was raised to 250
mmHg. Attention was directed to the dorsal medial surface of
the foot. Utilizing a 10 blade, a curvilinear incision was
made along the first metatarsophalangeal joint and across the
entire length of the proximal phalanx. The incision was
deepened using sharp and blunt dissection. Care was taken to
retract all vital neurovascular tendinous structures as well
as cauterize the bleeders. Initially, the lateral release was
inspected from previous surgery. Further dissection in order
to make that adequate release was noted. The symptoms were
also inspected and were noted to be adhered to the plantar
aspect of the first metatarsal.
At this point, an Akin osteotomy was carried out. Utilizing
an oscillating saw, an oblique osteotomy with the medial base
was carried out through and through. The osteotomy was
reduced and adequate reduction of the deformity was noted.
The osteotomy was then stabilized utilizing manufacturer's
guidelines. A 3-0 Stryker screw, 14 mm in length was ____.
Adequate compression was noted across the osteotomy site. At
this point, we elected to free the sesamoid. Utilizing a
freer and McGlamry elevator, sesamoid were freed from the head
of first metatarsal. This allowed for less tension to the
pulling the digit laterally. Soft tissue contracture of skin
was noted from previous scar around the second
metatarsophalangeal joint. It was elected that that would be
released at the time. A medial capsulorrhaphy was performed.
At this point, it was noted that there was the extensor tendon
had been cut. Utilizing 2-0 braided nylon, the extensor
tendon was reapproximated and was noted to be secure. The
capsule was then reapproximated with 2-0 Vicryl. There was a
small area devoid of capsule on the metatarsophalangeal joint
and it was elected to use a graft to overlay it. A TissueMend
graft was then placed over the void approximately 1.5 x 1 cm
in length to cover the area adequately. The skin was then
reapproximated with 3-0 nylon. V-Y tenoplasty was then
performed over the previous scar to the first interspace.
Incision was carried out with a 15 blade. Tissue was released.
Adequate release of contracture was noted.
The Y was then reapproximated using 4-0 nylon in a simple
interrupted method. At this point, the 2nd digit was noted to
be still slightly dorsiflexed, lateral aspect of the second
metatarsophalangeal joint. A small incision was made _____
dissection. The extensor tendon was identified as the tendon
lengthening was carried out. The tendon was noted to increase
in length and decrease tension of the second MPJ. Skin was
then reapproximated with a 3-0 nylon. Tourniquet was dropped
and ____ was noted to all digits of the patient's right foot.
Attention was directed to the left foot. Esmarch ____
exsanguinated, pneumatic ankle tourniquet was raised to 250
mmhg. Attention was then directed to the dorsal medial
surface. Utilizing a 10 blade, ____ incision was made over
the first metatarsophalangeal joint extending on to the
proximal phalanx. The incision was deepened using sharp and
blunt dissection. Care was taken to retract all vital
neurovascular tendinous structures. The capsule was
identified. A linear capsular incision was made. Capsule was
resected medially and laterally, bringing the
metatarsophalangeal joint to the surgical field. The
cartilage to the head of the proximal ____ was inspected and
was noted to be slightly deviated consistent with increased
____ angle. At this point, a ____ osteotomy was elected to be
performed utilizing sagittal saw. An initial cut was made
two-thirds of the way down the first metatarsal, 90 degrees
____. A second cut was then made 90 degrees articular
cartilage. The wedge was removed. The plantar shelf cut was
then carried out using oscillating saw. Immediately the
deformity was then collapsed. The capital fragment was then
shifted slightly laterally approximately 3 mm. Temporary
fixation was placed. Utilizing manufacturer's guidelines, a
Stryker 3.0 screw size ____ mm in length was placed. Adequate
reduction of the osteotomy was noted. Utilizing sagittal saw,
the medial redundant bone was resected. Rotary bur was used
as well in order to further contour the surface. The surgical
site was lavaged with copious amounts of saline mixed with
antibiotic. The capsule was reapproximated with 2-0 Vicryl
and the skin was closed with 3-0 nylon in horizontal mattress
technique. Using Betadine ointment, ____, Kling, Coban was
applied to bilateral feet. Tourniquet was dropped and ____ of
the patient's left foot.
PROCEDURE PERFORMED:
1. Akin osteotomy, right foot.
2. Lateral release with freeing of the sesamoids, right
foot.
3. V-Y tenoplasty, right foot.
4. Application of graft, right foot..
5. Extensor tenotomy 2nd MPJ, right foot.
6. First metatarsal osteotomy with screw fixation, left
foot.
PROCEDURE IN DETAIL: After reviewing patient history and
physical and noting no significant _____, the patient was
brought to operating room, placed on the operating table in
supine position. The surgeon, assistant, anesthesiologist,
nurses a timeout was called to verify the patient's name,
procedure to be performed, _____ performed. All present were
in agreement. Following adequate IV sedation, a local
anesthetic block was administered to the patient's right and
left foot in standard Mayo type fashion utilizing a total of
20 mL of 1% lidocaine plain. The patient's foot was then
scrubbed, prepped and draped in usual aseptic manner.
Attention was then directed to the patient's right foot.
Utilizing Esmarch bandage, the patient's right foot was
exsanguinated and pneumatic ankle tourniquet was raised to 250
mmHg. Attention was directed to the dorsal medial surface of
the foot. Utilizing a 10 blade, a curvilinear incision was
made along the first metatarsophalangeal joint and across the
entire length of the proximal phalanx. The incision was
deepened using sharp and blunt dissection. Care was taken to
retract all vital neurovascular tendinous structures as well
as cauterize the bleeders. Initially, the lateral release was
inspected from previous surgery. Further dissection in order
to make that adequate release was noted. The symptoms were
also inspected and were noted to be adhered to the plantar
aspect of the first metatarsal.
At this point, an Akin osteotomy was carried out. Utilizing
an oscillating saw, an oblique osteotomy with the medial base
was carried out through and through. The osteotomy was
reduced and adequate reduction of the deformity was noted.
The osteotomy was then stabilized utilizing manufacturer's
guidelines. A 3-0 Stryker screw, 14 mm in length was ____.
Adequate compression was noted across the osteotomy site. At
this point, we elected to free the sesamoid. Utilizing a
freer and McGlamry elevator, sesamoid were freed from the head
of first metatarsal. This allowed for less tension to the
pulling the digit laterally. Soft tissue contracture of skin
was noted from previous scar around the second
metatarsophalangeal joint. It was elected that that would be
released at the time. A medial capsulorrhaphy was performed.
At this point, it was noted that there was the extensor tendon
had been cut. Utilizing 2-0 braided nylon, the extensor
tendon was reapproximated and was noted to be secure. The
capsule was then reapproximated with 2-0 Vicryl. There was a
small area devoid of capsule on the metatarsophalangeal joint
and it was elected to use a graft to overlay it. A TissueMend
graft was then placed over the void approximately 1.5 x 1 cm
in length to cover the area adequately. The skin was then
reapproximated with 3-0 nylon. V-Y tenoplasty was then
performed over the previous scar to the first interspace.
Incision was carried out with a 15 blade. Tissue was released.
Adequate release of contracture was noted.
The Y was then reapproximated using 4-0 nylon in a simple
interrupted method. At this point, the 2nd digit was noted to
be still slightly dorsiflexed, lateral aspect of the second
metatarsophalangeal joint. A small incision was made _____
dissection. The extensor tendon was identified as the tendon
lengthening was carried out. The tendon was noted to increase
in length and decrease tension of the second MPJ. Skin was
then reapproximated with a 3-0 nylon. Tourniquet was dropped
and ____ was noted to all digits of the patient's right foot.
Attention was directed to the left foot. Esmarch ____
exsanguinated, pneumatic ankle tourniquet was raised to 250
mmhg. Attention was then directed to the dorsal medial
surface. Utilizing a 10 blade, ____ incision was made over
the first metatarsophalangeal joint extending on to the
proximal phalanx. The incision was deepened using sharp and
blunt dissection. Care was taken to retract all vital
neurovascular tendinous structures. The capsule was
identified. A linear capsular incision was made. Capsule was
resected medially and laterally, bringing the
metatarsophalangeal joint to the surgical field. The
cartilage to the head of the proximal ____ was inspected and
was noted to be slightly deviated consistent with increased
____ angle. At this point, a ____ osteotomy was elected to be
performed utilizing sagittal saw. An initial cut was made
two-thirds of the way down the first metatarsal, 90 degrees
____. A second cut was then made 90 degrees articular
cartilage. The wedge was removed. The plantar shelf cut was
then carried out using oscillating saw. Immediately the
deformity was then collapsed. The capital fragment was then
shifted slightly laterally approximately 3 mm. Temporary
fixation was placed. Utilizing manufacturer's guidelines, a
Stryker 3.0 screw size ____ mm in length was placed. Adequate
reduction of the osteotomy was noted. Utilizing sagittal saw,
the medial redundant bone was resected. Rotary bur was used
as well in order to further contour the surface. The surgical
site was lavaged with copious amounts of saline mixed with
antibiotic. The capsule was reapproximated with 2-0 Vicryl
and the skin was closed with 3-0 nylon in horizontal mattress
technique. Using Betadine ointment, ____, Kling, Coban was
applied to bilateral feet. Tourniquet was dropped and ____ of
the patient's left foot.