Can someone confirm me the code for the below procedure
13160
PREOPERATIVE DIAGNOSIS: Right leg posterior compartment fasciotomy wound.
POSTOPERATIVE DIAGNOSIS: Right leg posterior compartment fasciotomy wound.
PROCEDURE: Secondary closure of right leg, posterior compartment fasciotomy
wound.
INDICATIONS: A 73-year-old man, who presented to the hospital approximately a
week ago with right leg pain. The patient had just an extensive travel from
Burma to Japan to New York to North Caroline and then a car ride down to
Florida from North Caroline. I saw the patient on 03/06/2015 and at
that time, his calf was firm. Compartment pressure showed that the posterior
compartment was markedly elevated at 108. . However, there is a moderate to large size hematoma on
the calf muscle, approximately 5 cm in diameter. He was taken to surgery,
where he underwent fasciotomy in the posterior and deep compartments. The
muscle was viable. The patient was found to have a liquid hematoma in the
soleus muscle. This was evacuated. The patient had multiple bleeders from
multiple sites.The patient's renal function was stable. Benefits, risk of
right leg exploration, secondary closure of fasciotomy wound were discussed
with the patient and his wife. Risks reviewed included pain, bleeding,
infection, permanent leg weakness, numbness, pain. The patient agreed to
procedure.
PROCEDURE IN DETAIL: Informed consent was obtained. The patient was brought
to operating room and placed in supine position. Adequate anesthesia was
obtained using general endotracheal intubation. The patient's right leg was
prepped and draped in normal sterile fashion. The patient's muscle was all
viable and was contracted. Soleus muscle did have moderate edema present, but
the edema had decreased quite a bit. The wounds were irrigated out copiously
with normal saline and prior Surgicel was removed. Hemostasis was achieved
with electrocautery. The swelling had decreased quite a bit and by pulling
the skin edges together. The whole wound would be able to be approximated
with minimal tension. I placed two #19 round Blake drains, one deep to the
soleus muscle, one posterior to the soleus muscle. These were sewn in place
with heavy nylon. The skin was then closed with staples. After closure, the
muscle compartment was soft and compartment did not appear to be in any other
tension. Dressings were applied as well as including a 6-inch Ace wrap.
Estimated blood loss was 50 cc. Sponge, needle, and instrument counts were
correct at the end of the procedure. The patient was sent to recovery room in
stable condition.
13160
PREOPERATIVE DIAGNOSIS: Right leg posterior compartment fasciotomy wound.
POSTOPERATIVE DIAGNOSIS: Right leg posterior compartment fasciotomy wound.
PROCEDURE: Secondary closure of right leg, posterior compartment fasciotomy
wound.
INDICATIONS: A 73-year-old man, who presented to the hospital approximately a
week ago with right leg pain. The patient had just an extensive travel from
Burma to Japan to New York to North Caroline and then a car ride down to
Florida from North Caroline. I saw the patient on 03/06/2015 and at
that time, his calf was firm. Compartment pressure showed that the posterior
compartment was markedly elevated at 108. . However, there is a moderate to large size hematoma on
the calf muscle, approximately 5 cm in diameter. He was taken to surgery,
where he underwent fasciotomy in the posterior and deep compartments. The
muscle was viable. The patient was found to have a liquid hematoma in the
soleus muscle. This was evacuated. The patient had multiple bleeders from
multiple sites.The patient's renal function was stable. Benefits, risk of
right leg exploration, secondary closure of fasciotomy wound were discussed
with the patient and his wife. Risks reviewed included pain, bleeding,
infection, permanent leg weakness, numbness, pain. The patient agreed to
procedure.
PROCEDURE IN DETAIL: Informed consent was obtained. The patient was brought
to operating room and placed in supine position. Adequate anesthesia was
obtained using general endotracheal intubation. The patient's right leg was
prepped and draped in normal sterile fashion. The patient's muscle was all
viable and was contracted. Soleus muscle did have moderate edema present, but
the edema had decreased quite a bit. The wounds were irrigated out copiously
with normal saline and prior Surgicel was removed. Hemostasis was achieved
with electrocautery. The swelling had decreased quite a bit and by pulling
the skin edges together. The whole wound would be able to be approximated
with minimal tension. I placed two #19 round Blake drains, one deep to the
soleus muscle, one posterior to the soleus muscle. These were sewn in place
with heavy nylon. The skin was then closed with staples. After closure, the
muscle compartment was soft and compartment did not appear to be in any other
tension. Dressings were applied as well as including a 6-inch Ace wrap.
Estimated blood loss was 50 cc. Sponge, needle, and instrument counts were
correct at the end of the procedure. The patient was sent to recovery room in
stable condition.