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What would be the CPT code for the procedure described below?

John Posted Thu 04th of July, 2013 22:55:05 PM

PROCEDURE NOTE:
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Pre-Procedure Vital Signs - BP: 124/91, RA; P: 89; PS: 6/10; Time: 10:00
Position: Semi-fowler;

Landmarks were identified corresponding to the following neural points:
- Site: Right foot dorsum, Superficial Peroneal Nerve, 5 cm proximal to the first toe;

The region was surgically prepped and draped. A skin wheal was raised with 2% plain lidocaine and a ½ inch 30-Gauge needle. A regional field anesthetic was administered, using a 50/50 mixture of 2% lidocaine and 0.25% plain Bupivacaine, administered through a 1-1/2 inch, 25-gauge needle.

The skin was incised with a #15 blade to 2.5 cm; the incision was taken down to the depth of the fascial plane; blunt probe was used for dissection. Hemostasis was with local pressure.

A 16-gauge, 50 mm. cryo-probe was then introduced in stimulator mode, with initial settings at a milliampere setting of 0 to 10, frequency 1, and polarity, negative. After appropriate paresthesias were elicited, the nerve was located, electrically isolated and the cryo-mode was engaged for 60 seconds, commencing at -16 degrees centigrade. This was followed by a 30 second thaw cycle. The cryo-mode was then re-engaged for an additional three times for 30 seconds each time, and followed again by a 30 second thaw cycle.

Effective neurolysis was obtained at -55 to -65 degrees centigrade. The probe was then withdrawn. The wound was irrigated with normal saline. Hemostasis was with local pressure and cryo-application. Layer closure was effected with plain catgut. Using 4-0 silk and a cutting needle, the wound edges were approximated with interrupted sutures. The site was dressed in a sterile manner.

Blood loss was less than 30 cc's. The procedure was tolerated well with no adverse reactions noted and the vital signs were stable at discharge after a post-observation recovery period of 45 minutes. The unit employed was a Wallach Painblocker 5000 and the refrigerant was nitrous oxide. Post-procedure instructions were explained verbally and issued in writing to the patient.

Post-Procedure Vital Signs - BP: 130/91; P: 78; Time: 11:51

SuperCoder Answered Fri 05th of July, 2013 18:33:50 PM

Hi,

We have a separate tool named Supercoding-on-Demand to get the complete OP report coded. Please contact customer service Manney at 866-228-9252 Extn : 4165

Thanks

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