Hoping I can get some responses to this coding question, because I am coming up with a blank as far as the CPT code. Here is the procedure note:
PROCEDURE: Procedure performed is removal of foreign body from underneath the fingernail. Procedure time is 4:10 p.m.. Foreign body location is finger nail of right ring finger. Prior to the procedure, time-out was done, verifying patient's name, date of birth, and procedure to be performed. Patient was placed in a semi-supine position, skin was prepped with alcohol prep pads, and digit was anesthetized using 2-puncture digital block with infiltration of proximally 5 cc of 2% lidocaine without epinephrine, negative aspiration for blood, landmarks visualized and palpated, excellent anesthesia was achieved. Area was then prepped and draped in the usual sterile fashion, and the foreign body was found to be very deep, necessitating removal of the entire fingernail. A large wooden splinter was then removed, and the area was cleansed with copious amounts of tap water and inspected to make sure there were no remaining foreign bodies. The nail bed not require repair. After cleansing, the fingernail was then reinserted under the proximal nail fold and anchored in place using 3 simple interrupted sutures of 4-0 Vicryl material. Patient had a brief episode of near-syncope, likely vasovagal in origin, but did not fall or injure herself, and she quickly recovered. She was given 4 mg Zofran ODT for nausea, and her wound was dressed with bacitracin and bulky dressing. Other than near-syncope, there were no complications, blood loss was minimal, and otherwise patient tolerated the procedure very well. Her tetanus was up-to-date.
Any help will be appreciated. And Thank You, in advance.
PROCEDURE: Procedure performed is removal of foreign body from underneath the fingernail. Procedure time is 4:10 p.m.. Foreign body location is finger nail of right ring finger. Prior to the procedure, time-out was done, verifying patient's name, date of birth, and procedure to be performed. Patient was placed in a semi-supine position, skin was prepped with alcohol prep pads, and digit was anesthetized using 2-puncture digital block with infiltration of proximally 5 cc of 2% lidocaine without epinephrine, negative aspiration for blood, landmarks visualized and palpated, excellent anesthesia was achieved. Area was then prepped and draped in the usual sterile fashion, and the foreign body was found to be very deep, necessitating removal of the entire fingernail. A large wooden splinter was then removed, and the area was cleansed with copious amounts of tap water and inspected to make sure there were no remaining foreign bodies. The nail bed not require repair. After cleansing, the fingernail was then reinserted under the proximal nail fold and anchored in place using 3 simple interrupted sutures of 4-0 Vicryl material. Patient had a brief episode of near-syncope, likely vasovagal in origin, but did not fall or injure herself, and she quickly recovered. She was given 4 mg Zofran ODT for nausea, and her wound was dressed with bacitracin and bulky dressing. Other than near-syncope, there were no complications, blood loss was minimal, and otherwise patient tolerated the procedure very well. Her tetanus was up-to-date.
Any help will be appreciated. And Thank You, in advance.