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Thanks,
Teri
I think I’ve brainstorming stuff this time. The patient was in an accident (traumatic). This is the first time that this malunion of deltoid ligament of the right ankle has been observed. There was no documentation of earlier repair that could’ve resulted in such malunion.
Were it a bone fracture I would code with the ICD-10-CM Code for that fracture with initial encounter (following the concept of delay in treatment and hence the initial encounter code rather than the subsequent encounter malunion code). But in this case surprisingly the physician has stated the term malunion for a ligament.
1. I’m thinking of going with S93.421A. The problem is that the physician has not stated the term sprain explicitly.
2. Also, I was wondering about what the code would be if the ligament was repaired earlier and now presented with malunion? Would we code sprain subsequent encounter then or would we code through complication-postprocedural route? There is no code as such for sprain-ligament-subsequent encounter-malunion.
Am I wrong in extrapolating the fracture malunion concept to ligament malunion diagnosis?
Any thoughts?
Preoperative Diagnosis: Left ankle soft tissue mass
Procedure: Excision of ankle soft tissue mass
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in the supine position. The anesthesiologist then proceeded to provide general anesthesia and IV antibiotics. A tourniquet was placed on the left thigh and the left lower extremity was then scrubbed, prepped and draped in the usual aseptic manner. Utilizing an Esmarch bandage, the left lower extremity was exsanguinated and the tourniquet was inflated to 300 mmHg.
Attention was then directed toward the distal aspect of the left malleolus where a hard palpable mass of about 3 cm in diameter was appreciated distal to the tibia. A linear incision was made over this lesion, at which point, cystic fluid was noted. The incision was deepened around the lesion. All superficial bleeders were cauterized as necessary and all neurovascular structures were retracted. Utilizing sharp and blunt dissection, the lesion was excised, and the origin of the cystic fluid was cauterized. The cystic lesion was then sent off to pathology and the surgical site was then copiously flushed with antibiotic-impregnated saline solution.
The surgical site was reapproximated utilizing 3-0 Vicryl in a simple interrupted stitch fashion. Lastly, the sldn was reapproximated using 4-0 nylon in a horizontal mattress stitch fashion. The surgical site was then injected with 10 mL of Marcaine 0.5% plain for postoperative pain relief, and the procedure site was then dressed with Xeroform, 4 x 4 gauze, and Kling. The patient was placed in a Cam boot for postoperative protection. The patient tolerated surgery and anesthesia well and was returned to the postanesthesia care unit with all vital signs stable and intact.
Thank you!
Holly
The patient identified the bilateral ankles as the operative site. Consent was verified for the procedure. The patient was brought back and placed under general anesthesia. All bony prominences were subsequently padded as the patient was given 2 g of Ancef IV 30 minutes prior to starting the case. Bilateral lower extremities were prepped with sterile ChloraPrep and draped in sterilely appropriate fashion. Surgical procedure began with passing a guidewire percutaneously over the lateral aspect of the left ankle to engage the distal fibula. Intraoperative fluoroscopic imaging confirmed the appropriate starting position. The guidewire was then passed across the fracture while the fibula was maintained in reduced position with the manual reduction techniques. The outer cortex was breached and the screw was countersunk and a 5.5 cannulated screw was placed in the left fibula. Attention was then focused on the medial malleolar fractures. Percutaneous guidewires for 4.0 cannulated screws were placed; 4-0 cannulated screws were placed and intraoperative fluoroscopic imaging confirmed anatomic reduction and alignment. Intraoperative cotton test was negative for the left ankle. The surgical incisions were closed with sterile 2-0 nylon suture in Donati suture fashion.
Attention was then focused on the right ankle. A guidewire was passed up the fibula while the displaced fibula fracture was maintained with manual reduction techniques. The outer cortex was breached and countersunk as a 5.5 cannulated screw was placed, achieving rigid internal fixation. 4.0 stainless steel cannulated screws were then percutaneously placed across the medial malleolus achieving rigid internal fixation. Again, the surgical wounds were closed with sterile 2-0 nylon suture.
I’m looking into getting some on line help and I have noticed that there are several services out there. I was wondering if any of you can recommend which one to either go with, or stay away from?
I am trying to confirm if our surgeon can submit both cpt codes 27810 and 27814 done on the same day but different encounters. Pt was seen in ER and closed reduction was performed under conscious sedation. It was discussed with the pt and family since there still was displacement of the medial mallous fragment ORIF would be performed, pt went directly to OR from ER. Please advise and thank you in advance!
Operative report reads as follows:
DIAGNOSIS:
Left ankle fibula fracture with syndesmotic injury
PROCEDURE PERFORMED:
Left ankle closed reduction and percutaneous pinning
….A small stab incision was made over the medial malleolus and lateral malleolus. Using a large reduction clamp, the synostosis was then reduced. At this point in time, 2, 3.5 mm fully threaded cortical screws were placed through the fibula into the tibia, getting all 4 cortices and holding the syndesmosis in place. The reduction clamp was removed. X-rays showed appropriate
reduction and hardware placement. At this point in time, tourniquet was let down and there was no significant bleeding. #3-0 Nylon suture was used to close the incisions.
10 cc’s 0.25% Marcaine was injected into the incision site. A sterile, soft dressing was placed.