Medical Coding CPT, ICD-10-CM Codes
Patient number: 410327
Gender: Female
Body System: Musculoskeletal system
INDICATIONS: This is a 56 year old female with right hand ring finger trigger digit that has been recalcitrant to conservative treatment options. Patient wishes to proceed with surgical release. Risks, benefits, and alternatives to the procedure were discussed with the patient in detail preoperatively. Risks include, but not limited to, infection, damage to blood vessels or nerves, stiffness of fingers, thumb, and wrist, and need for further surgery. Patient verbalized understanding of these risk and consented to proceed. PREOPERATIVE DIAGNOSIS: Right hand ring finger trigger digit POSTOPERATIVE DIAGNOSIS: Right hand ring finger trigger digit OPERATION PERFORMED: Right hand ring finger trigger digit release SURGEON ASSISTANT SURGEON ANESTHESIA: Local with monitored anesthesia care COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Minimal TOURNIQUET TIME: 10 minutes at 250 mmHg FINDINGS: —- Complete release of the A 1 pulley with full passive flexion and extension of the affected digit without triggering. INDICATIONS: This is a 56 year old female with right hand ring finger trigger digit that has been recalcitrant to conservative treatment options. Patient wishes to proceed with surgical release. Risks, benefits, and alternatives to the procedure were discussed with the patient in detail preoperatively. Risks include, but not limited to, infection, damage to blood vessels or nerves, stiffness of fingers, thumb, and wrist, and need for further surgery. Patient verbalized understanding of these risk and consented to proceed. OPERATIVE NOTE: Patient was identified in the preoperative holding area and the correct surgical site was marked. Patient was then brought to the Operating Room where a formal time-out was performed to confirm the correct patient, site, and planned operation. Monitored anesthesia care was provided by the anesthesia team. A well padded tourniquet was placed on the upper arm. Patient was then prepped and draped in the usual sterile fashion. Local anesthetic was then injected superficially over the A 1 pulley of the affected digit. The hand was then exsanguinated and tourniquet inflated. An approximately 1 cm longitudinal incision was at the distal palmer crease over the A 1 pulley of the affected digit. We dissected through skin and subcutaneous tissue, being careful to retract the digital nerves. Tenotomy scissors were then used to carefully spread the underlying tissue and retractors place to expose the A 1 pulley. The A 1 pulley was then released sharply with the 15-blade midline. A tenotomy scissor was then used to complete the release proximally and distally. We then confirmed that there was no evidence of continued trigger. In addition, a Ragnell was used to pull the tendons out of the wound to confirm the complete release of A 1 pulley. The wound was then copiously irrigated and closed with two horizontal mattress 4-0 nylon sutures. Sterile dressing applied. Tourniquet was deflated and patient transferred to recovery room without incident in stable condition. VLab Outpatient Clinic Chart # 410327Identify the Primary procedure CPT codeIdentify the Primary Diagnosis ICD-10-CM codeIdentify the Secondary diagnoses ICD-10-CM code
