Medical Billing and Coding

Operative Report

Preoperative Diagnosis: Circular saw injury with complex laceration of left index finger withlacerationof extensor tendon and join capsule; laceration collateral ligament, radial side; displaced fracture at base of the middle phalanx, articular invovement.

 

Postoperative Diagnosis: Circular saw injury with complex laceration of left index finger iwth laceration collateral ligament, radial side; compound fracture, base of the middle phalanx, articular involvement.

 

Operative Performed

Debridement and repair extensor tendon and joint capsule. Repair radial collateral ligament and wound closure.

 

Anesthesia: Digital block

 

This is a 42-year-old white male who accidentally injured his left index finger on a circular saw while workingon broken shutters at home in his garage. The patient sustained a jagged laceration over the dorsal radial aspect of the index finger at the proximal interphalangeal joint. The wound was deep, involving the joint capsule, extensor tendon, and collateral ligament. The bone was also involved, especially at the base of the middle phalanx into the apical surface. The sensation to the tip of the finger was intact, especially all of the radial side. The wound measured about 3 cm in lenght.

 

Procedure: 0.5 percent Marcaine was used as local anesthetic digital block. After anesthesia had been obtained, the hand was prepped and draped int he usual manner. Tourniquet then was placed at the base of the fingers. The wound was then debrided. The minute loose bone and articular surface had to be removed. Some skin debrided. The minute loose bone and articular surface had to be removed. Some skin debrided also was removed. After satisfactory debridement, the joint capsule and extensor tendon then were repaired with 5-0 PDS suture material. The skin then was carefully approximated with 5-0 nylon. After completion, a dressing was applied. The tourniquet was released and there was good perfusion throughout the fingers. An aluminum splint was placed.

 

The patient received 1 g of Ancef in the emergency room. He will continue to take Keftab 500 mg twice daily for 4 days and Vicodin 1 tablet q.4h p.r.n. for pain. The postoperative instructions were given. Also the patient was informed about his injury and complications, especially wound infection and some stiffness of the finger. The patient will be followed up in my office.

 

Assign the correct codes and modifier for this encounter.

ICD-9-CM and CPT Code(s):_________________________________________

 

ICD-10-CM Code(s):_______________________________________________

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