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How would the following be coded?
PREOPERATIVE DIAGNOSIS
Cyst left third digit continuous with distal IPJ left third digit.
POSTOPERATIVE DIAGNOSIS
Cyst left third digit continuous with distal IPJ left third digit.
NAME OF OPERATION
Arthroplasty with biopsy of cyst and bone biopsy left third middle phalanx.
ANESTHESIA
IV sedation, local anesthetic block.
HEMOSTASIS: Ankle tourniquet 225 mmHg.
ESTIMATED BLOOD LOSS: Less than 5 mL.
MATERIALS: None.
INJECTABLES: 0.5% Marcaine, 1% lidocaine plain.
CONDITION: The patient was stable.
COMPLICATIONS: None.
INDICATIONS
The patient had recurrent cyst formation on the distal IPJ of the left third digit which did not resolve with conservative treatment. The patient has elected to have surgical resection of this in an attempt to relieve the patient of her symptoms, as well as confirm a diagnosis.
DESCRIPTION OF OPERATION
Under mild sedation the patient was brought to the Operating Room and placed on the operating room table in the supine position. Following IV sedation, local anesthetic block consisting of 0.5% Marcaine with 1% lidocaine plain was administered to the patient's left third digit. The patient's leg was scrubbed, prepped and draped in the usual aseptic manner. The patient's leg was elevated at 60 degrees for hemostasis, exsanguinated using an Esmarch bandage, at which time the pneumatic tourniquet was inflated to 225 mmHg.
Two semi-elliptical incisions were made in the transverse plane of the patient's third digit in the area of the distal IPJ third digit. Two semi-elliptical incisions were around the apparent glomus tumor, or cystic lesion on the distal IPJ. These two incisions connected and we gently removed this entire skin island from the wound en toto and sent it to pathology. At this time gently released the soft tissues around the distal IPJ, as well as performed a tenotomy of the extensor tendon and reflected the proximal one and used the sagittal saw to resect the head of the middle phalanx from the wound en toto. This, too, was sent to pathology. At this time I flushed the wound with copious amounts of sterile saline. There was no evidence of any infection, nor any abnormal tissue at this time and therefore I re-coapted the tendon using a 3-0 Vicryl in simple interrupted fashion and the skin closure was performed using 3-0 nylon in a simple interrupted fashion. The incision was injected with 2 mL of 0.5% Marcaine plain, dressed with Adaptic 4x4, Kling, Kerlix and Ace wrap. The pneumatic tourniquet deflated and a hyperemic response to all digits of the patient's left foot.
The patient tolerated the procedure and the anesthesia well without any complications, transported back to the Recovery Room with vital signs stable and vascular status intact to the left foot.
The patient was given instructions to keep the dressing clean, dry and intact, weightbear as tolerated in the surgical shoe, take pain medication as directed. Follow up in my office on Monday for postoperative check and re-evaluation and further recommendations.
PREOPERATIVE DIAGNOSIS
Cyst left third digit continuous with distal IPJ left third digit.
POSTOPERATIVE DIAGNOSIS
Cyst left third digit continuous with distal IPJ left third digit.
NAME OF OPERATION
Arthroplasty with biopsy of cyst and bone biopsy left third middle phalanx.
ANESTHESIA
IV sedation, local anesthetic block.
HEMOSTASIS: Ankle tourniquet 225 mmHg.
ESTIMATED BLOOD LOSS: Less than 5 mL.
MATERIALS: None.
INJECTABLES: 0.5% Marcaine, 1% lidocaine plain.
CONDITION: The patient was stable.
COMPLICATIONS: None.
INDICATIONS
The patient had recurrent cyst formation on the distal IPJ of the left third digit which did not resolve with conservative treatment. The patient has elected to have surgical resection of this in an attempt to relieve the patient of her symptoms, as well as confirm a diagnosis.
DESCRIPTION OF OPERATION
Under mild sedation the patient was brought to the Operating Room and placed on the operating room table in the supine position. Following IV sedation, local anesthetic block consisting of 0.5% Marcaine with 1% lidocaine plain was administered to the patient's left third digit. The patient's leg was scrubbed, prepped and draped in the usual aseptic manner. The patient's leg was elevated at 60 degrees for hemostasis, exsanguinated using an Esmarch bandage, at which time the pneumatic tourniquet was inflated to 225 mmHg.
Two semi-elliptical incisions were made in the transverse plane of the patient's third digit in the area of the distal IPJ third digit. Two semi-elliptical incisions were around the apparent glomus tumor, or cystic lesion on the distal IPJ. These two incisions connected and we gently removed this entire skin island from the wound en toto and sent it to pathology. At this time gently released the soft tissues around the distal IPJ, as well as performed a tenotomy of the extensor tendon and reflected the proximal one and used the sagittal saw to resect the head of the middle phalanx from the wound en toto. This, too, was sent to pathology. At this time I flushed the wound with copious amounts of sterile saline. There was no evidence of any infection, nor any abnormal tissue at this time and therefore I re-coapted the tendon using a 3-0 Vicryl in simple interrupted fashion and the skin closure was performed using 3-0 nylon in a simple interrupted fashion. The incision was injected with 2 mL of 0.5% Marcaine plain, dressed with Adaptic 4x4, Kling, Kerlix and Ace wrap. The pneumatic tourniquet deflated and a hyperemic response to all digits of the patient's left foot.
The patient tolerated the procedure and the anesthesia well without any complications, transported back to the Recovery Room with vital signs stable and vascular status intact to the left foot.
The patient was given instructions to keep the dressing clean, dry and intact, weightbear as tolerated in the surgical shoe, take pain medication as directed. Follow up in my office on Monday for postoperative check and re-evaluation and further recommendations.
