adricpc
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Need help me coding TFC Repair which was done arthroscopically and open. Don't know if it should be 25107, 29844 or 29846, 29844-59...
Here's the op report:
POSTOPERATIVE DIAGNOSIS: Right wrist triangular fibrocartilage tear.
OPERATION PERFORMED:
1. Right wrist arthroscopic partial synovectomy.
2. Right wrist arthroscopic triangular fibrocartilage repair.
IMPLANTS: None.
SPECIMENS: None.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: Not applicable.
COMPLICATIONS: None.
INDICATIONS FOR SURGERY: This patient is a 55-year-old gentleman who sustained injury to his right wrist. He presented with wrist pain in my office. His physical exam findings were suggestive of a triangular fibrocartilage injury. An MRI did in fact show a
tear. I explained to him the diagnosis and treatment options, both nonoperative and operative. Surgical procedure was explained
in detail including its risks, benefits, alternatives, and potential complications, also postoperative recovery. All of his questions were answered. He seemed to have an adequate understanding of what was involved and he desired to proceed with
surgery.
OPERATIVE PROCEDURE: The patient was seen in the preoperative holding area. Once again, I explained the planned surgical
procedures, risks, benefits, and alternatives, potential complications, verbal and written consent was obtained. The patient's right wrist was site marked. He was taken to the operative room and positioned on the operating room table, with all bony prominences well padded. Preoperative antibiotics and general anesthesia were administered. Tourniquet was applied to the patient's right upper arm. The arm was prepped and draped in the usual sterile fashion. A time-out was performed. The procedure was carried under the loupe magnification and bipolar electrocautery. The patient's right wrist was suspended with a traction device such that approximately 10 pounds of traction was placed across the radiocarpal joint. I placed a 25-gauge needle into the radiocarpal joint and insufflated the joint with 50:50 mixture of 1% lidocaine and 0.5% Marcaine with epinephrine. Following this, an incision was made directly over the 3-4 portal and a camera was inserted and a diagnostic wrist arthroscopy was performed. I first examined the radial side of the joint. Radial styloid and scaphoid appeared to be in good position as were all of the volar radiocarpal ligaments on that side. The scapholunate ligament was intact as was the ligament attached to. Cartilage on the scaphoid and lunate were in good condition. As I migrated from radial to ulnar, I began seeing more reddened and inflamed synovium and fraying of the tissues on that side of the joint. I made a second incision over the 6R portal, and through this incision, I placed a probe. I probed the triangular fibrocartilage and it did feel to be excessively lax. It did not have a normal trampoline effect. I then used the shaver to do a partial synovectomy involving the inflamed synovium and frayed tissue on the ulnar side of the joint. I debrided the triangular fibrocartilage to prepare it for a repair as an obvious tear was present from its ulnar attachment. I then made a third incision over the 4-5 portal and I switched the camera from the 3-4 portal position to the 4-5 portal position. I then advanced a meniscal repair cannula into the joint through the 3-4 portal and advanced it into the ulnar side of the joint. I then passed two 2-0 PDS sutures, both in a horizontal mattress fashion across the tear. Both of these sutures were advanced through the skin on the ulnar side of the wrist using a long needle. That concluded the arthroscopic portion of the procedure.
I next made a fourth incision to perform the direct repair of the triangular fibrocartilage by tying the suture on the dorsal and
ulnar side of the wrist capsule. I made an incision and bluntly dissected down to the capsule, making sure to identify and protect
the dorsal sensory branches of the ulnar nerve. Once these were identified, my assistant retracted them out of the way, so I could
continue to look for the 4 strands of suture. All 4 strands of suture were identified and brought through the incision, and then
each suture was individually tied while my assistant held direct pressure over the ulnar styloid. I made sure to tie these sutures
such that the knot was not placed over any vital structures, but rather directly on to the dorsal and ulnar side of the wrist capsule. Following this, the incisions were irrigated with saline. Each incision was closed with #4-0 Monocryl and then dressed sterilely with Xeroform gauze, a 4 x 4, and a Tegaderm dressing. A well-padded sugar-tong type splint was then applied to the patient's right upper extremity in order to prevent him from supinating and pronating. Lastly, the patient's right upper extremity was placed in a sling. He was then awakened from general anesthesia and taken to the recovery room without complication.
Any and all feedback welcome!
TIA
Adrienne Rabinowitz, CPC, CMRS, COSC
e-mail: adricpc@yahoo.com
Here's the op report:
POSTOPERATIVE DIAGNOSIS: Right wrist triangular fibrocartilage tear.
OPERATION PERFORMED:
1. Right wrist arthroscopic partial synovectomy.
2. Right wrist arthroscopic triangular fibrocartilage repair.
IMPLANTS: None.
SPECIMENS: None.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: Not applicable.
COMPLICATIONS: None.
INDICATIONS FOR SURGERY: This patient is a 55-year-old gentleman who sustained injury to his right wrist. He presented with wrist pain in my office. His physical exam findings were suggestive of a triangular fibrocartilage injury. An MRI did in fact show a
tear. I explained to him the diagnosis and treatment options, both nonoperative and operative. Surgical procedure was explained
in detail including its risks, benefits, alternatives, and potential complications, also postoperative recovery. All of his questions were answered. He seemed to have an adequate understanding of what was involved and he desired to proceed with
surgery.
OPERATIVE PROCEDURE: The patient was seen in the preoperative holding area. Once again, I explained the planned surgical
procedures, risks, benefits, and alternatives, potential complications, verbal and written consent was obtained. The patient's right wrist was site marked. He was taken to the operative room and positioned on the operating room table, with all bony prominences well padded. Preoperative antibiotics and general anesthesia were administered. Tourniquet was applied to the patient's right upper arm. The arm was prepped and draped in the usual sterile fashion. A time-out was performed. The procedure was carried under the loupe magnification and bipolar electrocautery. The patient's right wrist was suspended with a traction device such that approximately 10 pounds of traction was placed across the radiocarpal joint. I placed a 25-gauge needle into the radiocarpal joint and insufflated the joint with 50:50 mixture of 1% lidocaine and 0.5% Marcaine with epinephrine. Following this, an incision was made directly over the 3-4 portal and a camera was inserted and a diagnostic wrist arthroscopy was performed. I first examined the radial side of the joint. Radial styloid and scaphoid appeared to be in good position as were all of the volar radiocarpal ligaments on that side. The scapholunate ligament was intact as was the ligament attached to. Cartilage on the scaphoid and lunate were in good condition. As I migrated from radial to ulnar, I began seeing more reddened and inflamed synovium and fraying of the tissues on that side of the joint. I made a second incision over the 6R portal, and through this incision, I placed a probe. I probed the triangular fibrocartilage and it did feel to be excessively lax. It did not have a normal trampoline effect. I then used the shaver to do a partial synovectomy involving the inflamed synovium and frayed tissue on the ulnar side of the joint. I debrided the triangular fibrocartilage to prepare it for a repair as an obvious tear was present from its ulnar attachment. I then made a third incision over the 4-5 portal and I switched the camera from the 3-4 portal position to the 4-5 portal position. I then advanced a meniscal repair cannula into the joint through the 3-4 portal and advanced it into the ulnar side of the joint. I then passed two 2-0 PDS sutures, both in a horizontal mattress fashion across the tear. Both of these sutures were advanced through the skin on the ulnar side of the wrist using a long needle. That concluded the arthroscopic portion of the procedure.
I next made a fourth incision to perform the direct repair of the triangular fibrocartilage by tying the suture on the dorsal and
ulnar side of the wrist capsule. I made an incision and bluntly dissected down to the capsule, making sure to identify and protect
the dorsal sensory branches of the ulnar nerve. Once these were identified, my assistant retracted them out of the way, so I could
continue to look for the 4 strands of suture. All 4 strands of suture were identified and brought through the incision, and then
each suture was individually tied while my assistant held direct pressure over the ulnar styloid. I made sure to tie these sutures
such that the knot was not placed over any vital structures, but rather directly on to the dorsal and ulnar side of the wrist capsule. Following this, the incisions were irrigated with saline. Each incision was closed with #4-0 Monocryl and then dressed sterilely with Xeroform gauze, a 4 x 4, and a Tegaderm dressing. A well-padded sugar-tong type splint was then applied to the patient's right upper extremity in order to prevent him from supinating and pronating. Lastly, the patient's right upper extremity was placed in a sling. He was then awakened from general anesthesia and taken to the recovery room without complication.
Any and all feedback welcome!
TIA
Adrienne Rabinowitz, CPC, CMRS, COSC
e-mail: adricpc@yahoo.com
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