jenpollock
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Would appreciate some help with coding this case: Dr. did a primary repair of chronic hip abductor tendon tear. Would this be an unlisted procedure?
OP Note:*****************
PREOPERATIVE DIAGNOSIS:
Right hip: Abductor tendon tear.
Left hip: Abductor tendinosis.
OPERATION PERFORMED:
Right hip: Gluteus medius/abductor tendon repair.
Left hip: Injection, trochanteric bursa.
DESCRIPTION OF PROCEDURE:
Following induction of anesthesia, the patient received Ancef
parenterally. She was turned to a left lateral decubitus
position on a vacuum bag. Gel pads and pillows were used to pad
the lower extremities. The right upper extremity was placed on a
well limb holder. U-drape was used to isolate the hip area. The
right hip and lower extremity were prepped and draped in the
usual manner including an adherent Iodophor 3M drape.
A lateral incision was utilized. The iliotibial band was divided
and retracted. Gross tearing of the abductor was immediately
noted. This appeared chronic in nature. This involved at least
90% of the tendon area. Following definition of the anatomy,
progressive debridement of the abnormal tendon tissue was
performed. The medial and proximal-most aspect of the greater
trochanter were cleaned of soft tissue and curetted. CurvTek
drill holes were placed. FiberWire suture was then placed
through the main body of the gluteus medius tendon and brought
through the CurvTek drill holes. Reduction was performed with
the tendon apposed to bone. The FiberWire suture was tied over
the distal bone blocks. The tendon was repaired at its deep and
superficial layers utilizing Ethibond. Final lavage was
performed. The iliotibial band was repaired with interrupted
PDS. The remainder of the wound was closed in layers with Vicryl
with skin closed utilizing Monocryl subcuticular. Dermabond,
Benzoin and Steri-Strips were applied followed by a dry dressing.
Anesthesia was discontinued.
The patient was then returned to a supine position. The left
lateral hip area was prepped. The left trochanteric bursa was
injected with Xylocaine 1 ml and Depo-Medrol 80 mg.
CONDITION AT END OF PROCEDURE:
The patient was then transferred to the PACU in satisfactory
condition.
ESTIMATED BLOOD LOSS:
Zero.
***************
Any help would be appreciated!!
OP Note:*****************
PREOPERATIVE DIAGNOSIS:
Right hip: Abductor tendon tear.
Left hip: Abductor tendinosis.
OPERATION PERFORMED:
Right hip: Gluteus medius/abductor tendon repair.
Left hip: Injection, trochanteric bursa.
DESCRIPTION OF PROCEDURE:
Following induction of anesthesia, the patient received Ancef
parenterally. She was turned to a left lateral decubitus
position on a vacuum bag. Gel pads and pillows were used to pad
the lower extremities. The right upper extremity was placed on a
well limb holder. U-drape was used to isolate the hip area. The
right hip and lower extremity were prepped and draped in the
usual manner including an adherent Iodophor 3M drape.
A lateral incision was utilized. The iliotibial band was divided
and retracted. Gross tearing of the abductor was immediately
noted. This appeared chronic in nature. This involved at least
90% of the tendon area. Following definition of the anatomy,
progressive debridement of the abnormal tendon tissue was
performed. The medial and proximal-most aspect of the greater
trochanter were cleaned of soft tissue and curetted. CurvTek
drill holes were placed. FiberWire suture was then placed
through the main body of the gluteus medius tendon and brought
through the CurvTek drill holes. Reduction was performed with
the tendon apposed to bone. The FiberWire suture was tied over
the distal bone blocks. The tendon was repaired at its deep and
superficial layers utilizing Ethibond. Final lavage was
performed. The iliotibial band was repaired with interrupted
PDS. The remainder of the wound was closed in layers with Vicryl
with skin closed utilizing Monocryl subcuticular. Dermabond,
Benzoin and Steri-Strips were applied followed by a dry dressing.
Anesthesia was discontinued.
The patient was then returned to a supine position. The left
lateral hip area was prepped. The left trochanteric bursa was
injected with Xylocaine 1 ml and Depo-Medrol 80 mg.
CONDITION AT END OF PROCEDURE:
The patient was then transferred to the PACU in satisfactory
condition.
ESTIMATED BLOOD LOSS:
Zero.
***************
Any help would be appreciated!!