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Questions and Answers
What sutures were placed in a Bunnell-type fashion in both the proximal and distal portions of the Achilles' tendon?
No. 2 FiberWire®
What suture type was used to augment the repair after the main sutures were tied?
2-0 Vicryl suture
What was injected for postoperative pain control?
What was the total tourniquet time during the procedure?
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What type of fracture was diagnosed in Case 10?
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What procedure was performed on the patient's right ankle?
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What was used as an implant during the operation?
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The preoperative diagnosis for Case 10 was a __________.
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What complications were reported in the postoperative diagnosis for Case 10?
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What are the CPT® and ICD-10-CM codes reported for Case 1?
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What are the CPT® and ICD-10-CM codes reported for Case 2?
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What are the CPT® and ICD-10-CM codes reported for Case 3?
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What are the CPT® and ICD-10-CM codes reported for Case 4?
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What are the CPT® and ICD-10-CM codes reported for Case 5?
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What are the CPT® and ICD-10-CM codes reported for Case 6?
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What are the CPT® and ICD-10-CM codes reported for Case 7?
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What are the CPT® and ICD-10-CM codes reported for Case 8?
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What are the CPT® and ICD-10-CM codes reported for Case 9?
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Study Notes
Case 1: Open Treatment of Proximal Humerus Fracture
- Preoperative diagnosis: Comminuted left proximal humerus fracture.
- Procedure: Open treatment of left proximal humerus using DePuy GLOBAL® FX™ prosthesis.
- Anesthesia: General.
- Patient: 66-year-old female, sustained traumatic fracture.
- Details: Fracture fragments mobilized, replaced with a size 10 stem, cement injected, and bone graft placed for stabilization.
- CPT® code: 23616-LT; ICD-10-CM code: S42.202A.
Case 2: Kyphoplasty for Vertebral Compression Fracture
- Preoperative diagnosis: Painful L2 vertebral non-traumatic compression fracture.
- Procedure: L2 kyphoplasty performed under general anesthesia.
- Findings: Prior compression fractures at T11 and L1; fresh changes in L2 consistent with a fracture.
- Method: Percutaneous approach via Kyphon trocar, balloon inflation, and cement injection.
- CPT® code: 22514; ICD-10-CM code: M48.56XA.
Case 3: Fixation of Distal Radial Fracture
- Preoperative diagnosis: Comminuted intraarticular distal radial Colles' fracture, left wrist.
- Procedure: Closed reduction and application of uniplane fixation using fluoroscopy.
- Anesthesia: General.
- Technique: Pins placed under C-arm control, fracture reduced and fixed with clamps.
- CPT® codes: 20690-LT, 25605-51-LT; ICD-10-CM code: S52.532A.
Case 4: Elbow Dislocation and Fracture
- Preoperative diagnosis: Dislocation of right elbow with medial epicondyle fracture.
- Procedure: Closed reduction of dislocation and fracture under general anesthesia.
- Patient: 12-year-old male sustained elbow injury.
- Method: No skin incision performed, guided manipulation to achieve concentric reduction.
- CPT® codes: 24565-RT, 24605-51-RT; ICD-10-CM codes: S42.441A, S53.104A.
Case 5: Trigger Finger Release and Shoulder Injection
- Preoperative diagnoses: Right long finger trigger finger and left shoulder impingement.
- Procedures: Trigger finger release and injection in the shoulder via subacromial approach.
- Anesthesia: General.
- Shoulder injected with local anesthetics and corticosteroid.
- Finger surgery involved incision over A1 pulley, careful neurovascular management.
- CPT® codes: 26055-F7, 20610-51-LT; ICD-10-CM codes: M65.331, M75.52.
Case 6: Removal of Painful Hardware in Foot
- Preoperative diagnosis: Painful hardware, left foot post-fracture fixation.
- Procedure: Removal of screws in left foot under sedation and local anesthesia.
- Details: Incisions made over screw heads, screws removed, and incisions closed with nylon sutures.
- Postoperative condition: Patient stable; minimal blood loss; no complications.
- CPT® code: 20680-LT; ICD-10-CM codes: T84.84XA, G89.18.
Case 7: Trigger Point Injection
- Preoperative diagnosis: Right-sided thoracic pain in patient with metastatic right lung cancer.
- Procedure: Injection into rhomboid major, rhomboid minor, and levator scapulae muscles.
- White blood cell count managed with pain medication refills.
- Total of four injection points numbed and treated with Depo-Medrol.
- CPT® codes: 20553, J1030 x 4; ICD-10-CM codes: M54.6, C78.01.
Case 8: Plantar Fasciotomy
- Preoperative diagnosis: Plantar fasciitis, left.
- Procedure: Left plantar fasciotomy involving stab incision and fascia release.
- Anesthesia: General.
- Postoperative care: Injected with local anesthetic and dressed with compressive dressing.
- CPT® code: 28008-LT; ICD-10-CM code: M72.2.
Case 9: Open Repair of Achilles Tendon
- Preoperative diagnosis: Left Achilles' tendon rupture.
- Procedure: Open repair of the tendon performed under general anesthesia.
- Method: Incision made, rupture identified, and tendon re-approximated with sutures.
- Postoperative care: Antibiotic irrigation and cast application; pain management with Marcaine.
- CPT® code: 27650-LT; ICD-10-CM codes: S86.012A, W50.0XXA, Y93.67, Y99.8.
Case 10: Ankle Fracture Repair
- Preoperative diagnosis: Right ankle triplane fracture.
- Procedure: Open reduction and internal fixation (ORIF) of fracture.
- Anesthesia: General endotracheal.
- Specifics: Use of Synthes 4.0 mm cannulated screws for fixation.
- Complications: None documented.### Surgical Procedure Overview
- Patient consented and understood the procedure.
- Proceeded to the operating room with general anesthesia administered without complications.
- Preoperative antibiotics were administered as part of standard protocol.
Surgical Preparation
- Right lower extremity was prepared using alcohol and followed by Betadine prep to ensure sterility.
- A pointed reduction clamp was placed under X-ray guidance for accurate positioning.
Fracture Reduction
- A triplane fracture of the distal tibia was reduced, confirmed via AP and lateral X-ray imaging showing proper alignment.
- Guidewires from the Synthes 4.0 mm cannulated screw set were used; one placed medially along the anterior half of the epiphysis and parallel to the joint.
Screw Placement
- One screw was inserted above the physis from anterior to posterior to secure the fracture spike.
- Lengths of the wires were measured to select suitable partially threaded 4.0 mm cancellous screws.
- Screws were positioned correctly across the fracture site, confirmed by X-ray.
Post-Operative Care
- Wounds were copiously irrigated to prevent infection.
- Closure of the incision was performed using interrupted horizontal mattress 3-0 nylon suture for secure healing.
- A sterile compressive dressing was applied, and the limb was placed in a three-sided posterior mold splint.
Recovery and Complications
- Patient was extubated and transferred to recovery in stable condition.
- No complications occurred during the procedure.
- All surgical counts (sponge and needle) were confirmed accurate at the end of the operation.
Coding Information
- CPT code for the surgical procedure: 27827-RT
- ICD-10-CM code for the diagnosis: S82.391A
- Additional relevant ICD-10-CM code: W19.XXXA
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Description
Explore the essential concepts and practical applications of operative reports from AAPC Chapter 8. This quiz focuses on understanding preoperative and postoperative diagnoses, as well as the procedures and anesthetic information relevant to coding. Test your knowledge and enhance your skills in medical coding.
