How do I know what i can code for aside from the main procedure performed. I dont want to under code and I dont want to code for everything under the sun either. I just want some assistance. Here is an example of an op note i am coding and all I got so far was 27823-RT with DX S82.851A and maybe S93.431A. I feel off
EXAMPLE of OP NOTE
PREOPERATIVE DIAGNOSIS: Right ankle trimalleolar fracture with syndesmosis ligament tear.
POSTOPERATIVE DIAGNOSIS: Right ankle trimalleolar fracture with syndesmosis ligament tear.
OPERATION: Open reduction internal fixation of trimalleolar ankle fracture with open reduction internal fixation of syndesmosis and removal of external fixator.
ANESTHESIA: General.
COMPONENTS: Synthes 8-hole one-third tubular plate with 3 proximal cortical screws, 2 cortical interfragmentary screws, 1 distal cancellous screw and two 3.5 cortical syndesmosis screws through the plate. There were also two 4.0 partially-threaded cancellous screws in the medial malleolus.
CLINICAL HISTORY: This is a 44-year-old male who injured his ankle approximately 2 weeks ago. He had a fracture-dislocation of his ankle with a comminuted fracture in his talus in the syndesmosis between the fibula and distal tibia. Initially, I performed a closed reduction under anesthesia with external fixation, because of the significant soft tissue injury, placed to allow the swelling to decrease and the fracture blisters to improve. We discussed previously that this would be a staged procedure with the external fixator first and open reduction internal fixation second. We talked about the surgery for definite treatment with an ORIF. He understood the surgical risks including, but not limited to the risks of infection, blood loss, anesthesia, possible need for repeat surgery, possible incomplete relief of his pain, period of limited activity with convalescence, possible heart attack, blood clot, death, etc. He understood the external fixator would be removed and the hardware would be placed internally. He understood that he would be non-weight bearing after the surgery for likely at least 6 more weeks. He wanted to proceed with surgery.
OPERATIVE PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. Anesthesia was administered by the anesthesia staff. A nonsterile tourniquet was placed on the right thigh and the external fixator was tended to. The screws were loosened and the connectors and the bars were removed. The pins in the tibial shaft were removed manually. The pin sites were not infected and looked good. The transcalcaneal pin was left in place for traction purposes during the procedure. A sterile prep and drape of the right lower extremity was performed in the usual orthopaedic fashion and a timeout was used to identify the patient and procedure. The medial and lateral malleoli were palpated and the skin marker was used to draw out the malleoli and a skin incision marked out both medially and laterally. The lateral incision was based in the posterior half of the distal fibula. Skin incision was made sharply with a knife through the skin and subcutaneous tissue. Small bleeders were cauterized with the Boyle. Blunt dissection was performed down with scissors to the distal
fragment on the lateral malleolus fracture. This was a tong oblique fracture and this was followed proximally to the fracture site and the proximal portion of the fracture the fracture over top of the muscle here was split in line with the skin incision. The peroneal musculature was retracted posteriorly to expose the proximal side of the fracture. We evaluated a fracture hematoma and a freer elevator was used in the fracture site to open this and the hematoma was cleaned with a freer as well as with some irrigation. Hohmann retractors were placed anteriorly in the fracture site and with traction on the calcaneal pin as well as the lobster claw clamp, reduction maneuver was made. This was clamped and held in place with 2 lobster claw clamps that showed a very good near anatomic reduction of the fracture. Two anterior to posterior lag screws were made over-drilling the near cortex with a 3.5 drill and the far cortex with a 2.5 drill for compression across the fracture. These were measured and filled to the appropriate depth with excellent compression and maintenance of reduction. The clamp was removed and an 8-hole Synthes one-third tubular plate was obtained. This was positioned on the lateral side of the fibula and clamped in place. Fluoroscopic imagery was obtained and showed good position with the most distal screw in the metaphyseal area of the distal fibula and the second and third most distal screws being in appropriate position for syndesmosis fixation. With this in place, the second most proximal screw hole was drilled and filled to the appropriate depth with a cortical screw and the most distal hole was drilled and filled to the appropriate depth with a cancellous screw. These had good bites and fluoro imagery showed it to be in good position and maintained position for the syndesmosis fixation in the second and third most distal screw holes. The first most proximal and the third most proximal screw holes were on the proximal fragment and drilled and filled to the appropriate depth with cortical screws. Fluoro imagery showed this to remain in good position and the lateral image showed this to be in very good reduction and the posterior malleolus fragment that was less than 10% of the articular surface to be in a well-reduced position as well. It was determined to go medial at this point and the skin incision was made over the medial malleolus sharply with a knife through skin and subcutaneous tissues. Small bleeders were cauterized with the Boyle. Blunt dissection with scissors was performed down on the medial malleolus fracture. This was opened at the fracture site with a freer elevator and was irrigated with normal saline bulb syringe. The medial wall of the talus showed no evidence of significant injury on the articular surface. The fracture was allowed to fall back into position and a drill hole was made proximal to the fracture site and a point-of-reduction clamp was placed in the drill hole, applied to the medial malleolus in compressed reduction. Fluoro imagery in the AP and mortise views showed this to be a very good near anatomic reduction. Two 2.5 drill bits were drilled into the medial malleolus in a parallel position across the fracture site. These were visualized fluoroscopically, not impinging on the joint and in good position. The most anterior drill bit was removed and a 50 mm partially-threaded 4.0 screw was inserted with good compression and then the posterior bit was removed and also compressed across the fracture. This showed very good reduction on inspection. There was some slight comminution on the most anterior cortex, but fluoro imagery showed the mortise to be restored and the alignment to be near anatomic reduction both medially and laterally. It was determined next to fixate the syndesmosis and a large clamp was placed from the lateral side across the medial side with compression across the syndesmosis.. Fluoroscopic guidance was used to drill through 4 cortices, first from the second most distal hole and this was filled with a fully-threaded cortical screw and also through the third most distal hole through 4 cortices with a fully-threaded cortical screw in a parallel fashion. Final fluoro imagery in the AP, lateral and mortise views showed this to have a good reduction of the
syndesmosis with near anatomic reduction of the fractures. The posterior malleolus remained un-fixated, but in a well-reduced position and the mortise to be restored. Copious irrigation was performed in both wounds with bulb syringe normal saline. The subcutaneous tissue was closed with 2-0 Vicryl in interrupted fashion and 4-0 nylon in horizontal mattress fashion In the skin. Xeroform and sterile dry dressing were applied after the transcalcaneal pin was removed manually and the pin holes in the tibia and the calcaneus were curetted with a curette and irrigated with saline. These were not closed, but with a dressing intact. The tourniquet was deflated. A posterior splint was applied with the foot in neutral dorsiflexion. The patient was awakened and taken to recovery room and doing well