I am trying to code this op report and I think I'm trying to make this too hard. Can someone please assist?
I thinking 11012x2 for the open fracture debridement and 20693 for the removal and reapplication of the external fixator?
PRE-OP DIAGNOSIS: Open fractures right distal radius and distal ulna, laceration right extensor carpi ulnaris and extensor pollicis longus
PROCEDURE:
1. Irrigation and debridement of fractures right distal radius and right distal ulna with excision of skin, muscle and bone
2. Partial removal and reapplication of external fixator right upper extremity
Findings: Small amount of skin, muscle and bone was excised. *I removed the ulnar bar from the*fixator at the initial portion of the case and reapplied this at the end of the case. *C-arm showed satisfactory alignment.
*
Description of procedure: After he was under general anesthesia a padded tourniquet was applied to the right upper arm.*I removed his Hemovac drain. *I removed the ulnar bar from the fixator leading the radial bar in place so that the fracture alignment was maintained. *The right upper extremity was cleaned and then prepped and draped in standard sterile fashion. *A timeout was performed.
*
The removed bar and supports from the fixator were flashed during the case before reapplication.
There is no sign of infection. *The skin edges were cleaned removing small amount of dry blood. *Skin edges were freshened with pickups and scissors as needed. *The extensor pollicis longus proximal and distal stumps as well as the proximal and distal stumps of the extensor carpi ulnaris tendon were identified and were tagged from the prior surgery with Prolene suture. *The wounds were thoroughly irrigated with 6 L of gravity irrigation while gently curetting the fractures of the distal ulna removing hematoma. *The radius fracture was irrigated through the more radial lacerations.There was no sign of infection. *The wounds were again cleaned with Ray-Tec sponges and explored. *A small piece of bone less than 3 mm in size was removed from the proximal radial wound with no soft tissue attachment. *The ulnar fracture was very comminuted but there did not appear to be any bone fragments remaining that did not have soft tissue attachments. *The wounds were irrigated with an additional 3 L of gravity irrigation. *Some of the muscle and the proximal ECU stump was dark and this muscle was excised with pickups and scissors.
*
A medium Hemovac drain was placed from the ulnar wound exiting proximal to the incision. *The drain was not sewn in place. *The lacerations were then closed with 3-0 Prolene sutures achieving good primary closure. *The Hemovac was then hooked to suction. *The pin sites and lacerations were dressed with Xeroform, gauze, bulky Kerlix. *I then reapplied the ulnar bar of the fixator. *Fluoroscopy was brought in to confirm satisfactory alignment of the comminuted fractures of the distal radius and distal ulna on 2 views. *These images were saved.
Thanks,
I thinking 11012x2 for the open fracture debridement and 20693 for the removal and reapplication of the external fixator?
PRE-OP DIAGNOSIS: Open fractures right distal radius and distal ulna, laceration right extensor carpi ulnaris and extensor pollicis longus
PROCEDURE:
1. Irrigation and debridement of fractures right distal radius and right distal ulna with excision of skin, muscle and bone
2. Partial removal and reapplication of external fixator right upper extremity
Findings: Small amount of skin, muscle and bone was excised. *I removed the ulnar bar from the*fixator at the initial portion of the case and reapplied this at the end of the case. *C-arm showed satisfactory alignment.
*
Description of procedure: After he was under general anesthesia a padded tourniquet was applied to the right upper arm.*I removed his Hemovac drain. *I removed the ulnar bar from the fixator leading the radial bar in place so that the fracture alignment was maintained. *The right upper extremity was cleaned and then prepped and draped in standard sterile fashion. *A timeout was performed.
*
The removed bar and supports from the fixator were flashed during the case before reapplication.
There is no sign of infection. *The skin edges were cleaned removing small amount of dry blood. *Skin edges were freshened with pickups and scissors as needed. *The extensor pollicis longus proximal and distal stumps as well as the proximal and distal stumps of the extensor carpi ulnaris tendon were identified and were tagged from the prior surgery with Prolene suture. *The wounds were thoroughly irrigated with 6 L of gravity irrigation while gently curetting the fractures of the distal ulna removing hematoma. *The radius fracture was irrigated through the more radial lacerations.There was no sign of infection. *The wounds were again cleaned with Ray-Tec sponges and explored. *A small piece of bone less than 3 mm in size was removed from the proximal radial wound with no soft tissue attachment. *The ulnar fracture was very comminuted but there did not appear to be any bone fragments remaining that did not have soft tissue attachments. *The wounds were irrigated with an additional 3 L of gravity irrigation. *Some of the muscle and the proximal ECU stump was dark and this muscle was excised with pickups and scissors.
*
A medium Hemovac drain was placed from the ulnar wound exiting proximal to the incision. *The drain was not sewn in place. *The lacerations were then closed with 3-0 Prolene sutures achieving good primary closure. *The Hemovac was then hooked to suction. *The pin sites and lacerations were dressed with Xeroform, gauze, bulky Kerlix. *I then reapplied the ulnar bar of the fixator. *Fluoroscopy was brought in to confirm satisfactory alignment of the comminuted fractures of the distal radius and distal ulna on 2 views. *These images were saved.
Thanks,