ReignRuby
Contributor
I am needing help coding the following:
POSTOPERATIVE DIAGNOSIS: Fracture of the proximal phalanx, left long finger.
PROCEDURES PERFORMED: Open reduction and internal fixation of the left long finger proximal phalanx
INDICATIONS FOR PROCEDURE: This is a female who previously underwent an osteotomy for correction of a malunion of the left long finger proximal phalanx. During the postoperative period, the patient had returned to work under the restrictions of one handed duty and was noncompliant with the restrictions. The patient states she was mopping using both hands slipped and fell on to her operative hand, which resulted in displacement of the proximal phalanx through the osteotomy site, which was still healing. This resulted in increased pain and dorsal and angular displacement at the osteotomy site. She was seen in the office, repeat x-rays demonstrated the above mentioned findings and surgery was recommended for repeat internal fixation.
Attention was then given to the left long finger. Using a 15-blade scalpel, a midlateral incision was made along the radial aspect of the proximal phalanx of the left long finger through the previous incision. Careful dissection was taken down to the radial border of the extensor mechanism. This was incised with a 15-blade scalpel exposing the bone and the large amount of scar tissue and callus. The callus was removed using a rongeur, pickups and tenotomy scissors. The fracture site was identified. The fracture site was gapped open and any debris within the fracture was removed, which did include some scar tissue and callus formation. Both edges of the fracture were freshened up using a rongeur to allow adequate compression. Next, using a bone clamp, the fracture was compressed and three 0.045 K-wires were placed bridging the fracture site. The bone clamp was removed and rotation was assessed, which was found to be satisfactory and symmetric using the tenodesis effect. Fluoroscopy was used during the entire case to confirm satisfactory reduction and adequate fixation. The K-wires were bent and trimmed.
This is within 90 days of the initial procedure. I am thinking ICD10 S62.613A or P. It is a new injury. CPT 26735-78 for the ORIF. Thoughts?
POSTOPERATIVE DIAGNOSIS: Fracture of the proximal phalanx, left long finger.
PROCEDURES PERFORMED: Open reduction and internal fixation of the left long finger proximal phalanx
INDICATIONS FOR PROCEDURE: This is a female who previously underwent an osteotomy for correction of a malunion of the left long finger proximal phalanx. During the postoperative period, the patient had returned to work under the restrictions of one handed duty and was noncompliant with the restrictions. The patient states she was mopping using both hands slipped and fell on to her operative hand, which resulted in displacement of the proximal phalanx through the osteotomy site, which was still healing. This resulted in increased pain and dorsal and angular displacement at the osteotomy site. She was seen in the office, repeat x-rays demonstrated the above mentioned findings and surgery was recommended for repeat internal fixation.
Attention was then given to the left long finger. Using a 15-blade scalpel, a midlateral incision was made along the radial aspect of the proximal phalanx of the left long finger through the previous incision. Careful dissection was taken down to the radial border of the extensor mechanism. This was incised with a 15-blade scalpel exposing the bone and the large amount of scar tissue and callus. The callus was removed using a rongeur, pickups and tenotomy scissors. The fracture site was identified. The fracture site was gapped open and any debris within the fracture was removed, which did include some scar tissue and callus formation. Both edges of the fracture were freshened up using a rongeur to allow adequate compression. Next, using a bone clamp, the fracture was compressed and three 0.045 K-wires were placed bridging the fracture site. The bone clamp was removed and rotation was assessed, which was found to be satisfactory and symmetric using the tenodesis effect. Fluoroscopy was used during the entire case to confirm satisfactory reduction and adequate fixation. The K-wires were bent and trimmed.
This is within 90 days of the initial procedure. I am thinking ICD10 S62.613A or P. It is a new injury. CPT 26735-78 for the ORIF. Thoughts?