Question

Assign CPT and ICD-10-CM codes to this Surgery Musculoskeletal System Service.

LOCATION: Inpatient, Hospital

PATIENT: Debbie Pedersen

PRIMARY CARE PHYSICIAN: Frank Gaul, MD

SURGEON: Mohomad Almaz, MD

DIAGNOSIS: Left type II closed supracondylar humerus fracture, posterior lateral displacement, after fall from playground equipment.

INDICATIONS: Debbie is an 8-year-old girl who fell today from the playground and suffered a type II closed supracondylar humerus fracture with posterior lateral displacement. I have spoken with her parents and reviewed the intended procedure, risks, and potential complications. Her parents have agreed with the treatment plan and wish to proceed.

PROCEDURE PERFORMED: Closed reduction initially, followed by open treatment of supracondylar fracture.

ANESTHESIA: General

PROCEDURE: Debbie was brought to the operating room. She fell from playground equipment today. She was placed under general anesthesia. She was transferred to the operating room table. Prior to prepping and draping her left upper extremity, I was able to again obtain pulses. I did initially bring in the mini C-arm. A closed reduction was performed initially by milking the brachialis primarily laterally. While this was being done, I did apply extension, felt a reduction. I then subsequently flexed the elbow with pressure on the posterior aspect of the distal humerus. After the elbow was flexed, I subsequently externally rotated and pronated the forearm. Overall, I actually had a very reasonable reduction. After this was performed, I felt that I could repeat this, so her left arm was prepped and draped in the usual sterile manner. Starting laterally, a small incision was made over the lateral epicondyle. Blunt dissection was taken down to the bone. One 0.064 mm K-wire was placed through the lateral epicondyle, across the fracture, engaging the medial column and medial cortex. Its position was confirmed on AP and lateral radiographs. A second K-wire was placed just posterior to this, extending proximally into the lateral column. This did also penetrate just to the anterior cortex. Position was confirmed on AP and lateral radiographs and had acceptable position, alignment and reduction. After this was performed, the arm was again fully externally rotated. The medial epicondyle was felt. I did feel the proximal location of the ulnar nerve. An incision was taken through the skin. Blunt dissection was taken through subcutaneous tissue. I actually was able to find the nerve in this, so subsequently retracted posteriorly. Blunt dissection was made directly to the medial epicondyle. Under direct visualization, the K-wire was placed through the medial epicondyle, across the fracture and through the lateral column of the humeral metaphysis. Overall alignment and position were deemed acceptable. No tourniquet was used. With the arm under live fluoroscopy, I did extend the elbow to approximately 90 degrees. Of note, to maintain the reduction, I did hold her arm in full flexion and pronation and subsequently Cobaned her arm in this position. Again, the Coban was released, the arm was taken to 90 degrees, and her fingers were pink, warm, with brisk refill. I utilized a Doppler and was able to get good Doppler radial and ulnar pulses. I was able to palpate a radial pulse. Medially, the wound was irrigated. The skin was closed with nylon sutures. Laterally, I did have to release the pin site and one suture was used to reapproximate the incision. Xeroform was placed. The pins were cut and bent. Soft roll was placed. She was placed in the posterior splint with reinforcement medially. She was awakened, extubated, and taken to recovery uneventfully. Her fingers again, after the splint was placed, were pink and demonstrated brisk capillary refill.

PLAN: We will keep her overnight. I did inject her incision and pin sites both medially and laterally with a total of 12 cc of 0.25% Marcaine without epinephrine. We likely will be able to dismiss her tomorrow to go home. She tolerated the above operative procedure with no known complications.

Answer 1

ICD-10-CM classification stands for The International Classification of Diseases,Tenth Division,Clinical Modification.It is a system used by the physician and health care providers to classify and code all symptoms,diagnoses,and procedures in United States and around the world.

CPT stands for Current Procedures Terminology is a medical code is used for coding of procedures

*Here the patient is Debbie Pederson

Her diagnosis is Supracondylar humerus fracture of left type II closed with posterior lateral dispalcement after fall from a playground equipment.

The ICD-10-CM classification for Debbie Pederson is S00-T88,why because the fracture of humerus is as a result from the consequences of external causes that is from an playground equipment fall

The injury is occured to the Musculo skeletal system,thus we can apply one more ICD-10-CM Code for Debbie penderson is M00-M99

The CPT procedure code for Debbie Pederson:

Hospital inpatient services:99221-99239

Musculoskeletal System Surgery CPT Code:20000-29999

AP and Lateral radiography/Radiology Procedure of the left hand:70010-76499

Fluoroscopic guidance for placement:77001-77022

Planning for inject her incision with 0.25% Maricane:01710-01782