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Ortho Operative Report

B Posted Wed 24th of August, 2016 13:39:08 PM
I need to know how to properly code this procedure and the diagnosis given in the op report: Diagnosis: Right elbow cubital tunnel syndrome. Procedure: 1 . Right elbow cubital tunnel release . 2 . Anterior subcutaneous transposition of the ulnar nerve . 3 . Epineurolysis ulnar nerve I Lys)s of adhesions ANESTHESIA: Laryngeal mask airway. DESCRIPTION OF PROCEDURE: The patient was brought into the operating suite and placed supine on the operating table. Then, 600 mg of IV clindamycin was given for preoperative antibiotics as the patient. has allergy to penicillin . Her right a rm was placed on an arm board . A tourniquet was applied to the p r oximal arm and preset to 250 mmHg of pressure . The patient was then placed under adequate laryngeal mask airway anes thesia. An Esmarch bandage was utilized to exsanguinate the l i mb and tourniquet was inflated . Time out was performed, the pat ient' s identity and procedure and right side was confirmed and the procedure was commenced. An incision was made from 5- cm distal to the medial epicondyle to several centimeters proximal on the right elbow . The incision was carried through the subcutaneous tissue wit h littler scissors and spreading technique. Electrocautery was utilized as needed . The cubL:al tunnel was then entered bluntly with a mosquito clamp over which the 15- blade was utili zed to transect the aponeurosis . Cubital tunnel release was performed e xposing the ulnar nerve . Vessel loops were placed around the ulnar nerve for manipulation . Dissection was carr ied p r oximally to the intermuscular s eptum . Digital palpation revealed no obstructions proximally . Dissection was then carried distally to the flexor retinaculum and aponeurosis1 and the ulnar nerve was freed and transposed anteriorly. Attention was given for proper orientation of the nerve and aqequate placements. Next, util izing 4- 0 Vicryl , subcutaneous transposition was performed by suturing the subcutaneous tissue of the flap posterior to the nerve to prevent the nerve subluxating posteriorly . An adequate nerve bed was created and the nerve was placed in the subcutaneous tissue without undue tension . The proximal and di stal extents of the nerve were noted to be free of kinking or undue tension. The cubital tunnel was then reapproximated with 4- 0 simple and mattress- type sutures. At this point, tourniquet was released at 25 minutes and hemostasis was achieved. The wound was thoroughly irrigated. The subcutaneous tissue was closed wi t h 4- 0 Vicryl sutures and the skin was '::losed with 3- 0 nylon horizontal mattress sutures. Xeroform was applied. Sterile dre s s ings were applied and the arm was wrapped with Ace wrap wi thout t ension . An arm sling was applied. The patient was then ~wakened , the LMA removed, and she was placed on a transport bed and taken to recovery room in stabl e condition . Blood loss was minimal. The patient tolerated the procedure we ll . Sponge, needle and instrument counts were correct at the end of the case . Total tourniquet time was 25 minutes .
SuperCoder Answered Thu 25th of August, 2016 01:04:04 AM

hi,

AAE does not provide coding for operative reports and chart notes.

SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail customerservice@supercoder.com for more information.

B Posted Tue 30th of August, 2016 19:55:37 PM
ok can I get the correct codes for Diagnosis- Right elbow cubital tunnel syndrome CPT- Right elbow cubital tunnel release Anterior subcutaneous transposition of the ulnar nerve Epineurolysis ulnar nerve
B Posted Tue 30th of August, 2016 19:58:17 PM
ok can I get the correct codes for Diagnosis- Right elbow cubital tunnel syndrome CPT- Right elbow cubital tunnel release, Anterior subcutaneous transposition of the ulnar nerve and Epineurolysis ulnar nerve
SuperCoder Answered Wed 31st of August, 2016 01:05:29 AM

Hi,

Diagnosis code for Right elbow cubital tunnel syndrome is G56.21.

Thanks

B Posted Wed 31st of August, 2016 08:17:17 AM
thank you. How about the procedure code for Right elbow cubital tunnel release, Anterior subcutaneous transposition of the ulnar nerve and Epineurolysis ulnar nerv
B Posted Wed 31st of August, 2016 11:05:49 AM
Basically the doctor did a Right elbow cubital tunnel release, an anterior subcutaneous transposition of the ulnar never, an Epineurolysis of the ulnar nerve ad a Lysis of adhesion. I believe CPT 64718 cover the cubital tunnel release, the anterior subcutaneous transposition of the ulnar never, and the Epineurolysis of the ulnar nerve. However, I cannot find anywhere how to code the Lysis of adhesion for that particular area? Also, I only bill cpt 64718 once, correct?
SuperCoder Answered Thu 01st of September, 2016 01:23:41 AM

Hi,

64718-RT seems the correct code choice. There is no particular code for reporting lysis of adhesion for that particular area. I could not see removal of adhesion in the documentation provided by you in detailed operative report. You will report code once.

Thanks

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