Question

week 5 Surgery for Outpatient

assign CPT and ICD-10-CM codes?

Surgery Case-003

PREOPERATIVE DIAGNOSIS: Retained metal, left knee. POSTOPERATIVE DIAGNOSIS: 1. Retained metal, left knee 2. Tear anterior horn of medial meniscus 3. Type II Diabetes PROCEDURES PERFORMED: Arthroscopic examination of the left knee with metal (screws) removal, medial meniscectomy. ANESTHESIA: Spinal. ESTIMATED BLOOD LOSS: Minimal. This 39-year-old male suffered with discomfort in his left knee due to retained hardware from a previous ORIF of a medial femoral condyle fracture. PROCEDURE: After an appropriate level of anesthesia was achieved, the left leg was prepped and draped in orthopedic manner. We made initially two portals, one medial and the other lateral to the patellar tendon. Sharp dissection was carried through the skin and blunt dissection carried into the joint space. On examination of the knee, we appreciated that the lateral compartment was in good condition. There was an anterior horn tear of the medial meniscus that was debrided back to stable tissue. The patient had grade 2 chondromalacia in a diffuse manner involving the medial compartment. The anterior cruciate ligament was probed and felt to be essentially intact. The PCL was noted to be present also. We used our shavers to identify the screws medially on the medial femoral condyle. We got back to the posterior medial corner. We had to make three stab wounds for each of the screws. We did this first with a needle, then sharp dissection through the skin and blunt dissection carried into the joint space. We then backed the screws out. We then appreciated on x-ray that the patient had a rather large spur involving the medial condyle. Upon probing and looking at the medial condyle, this was very posterior, did not appear to be particularly medial. No attempt was made to debride it. We then irrigated the wound, closed the wound with interrupted nylon sutures, and placed the patient in a knee immobilizer. The patient appeared to tolerate the procedure well and left the operating room in good condition.

Pathology Report Later Indicated: Necrotic tissue.

Answer 1

ORIF- OPEN REDUCTION INTERNAL FIXATION.

Z18.9 - retained foreign body fragments, unspecified material. Z18.9 is a specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

ORIF- Open Reduction and Internal Fixation is a surgical procedure to treat a fractured bones. Physiotherapy is required as soon as the patient undergone the surgery to reduce pain, stiffness and improve mobility, range of movement and strength in the affected knee. Depending on the severity of fracture, the rehabilitation can take 4 or more months for the patient to complete. The goals include a) to restore a pain free on the fracture site b) to restore full range of motion c) to restore full muscle strength d) to restore full muscle length and flexibility e) to improve cardiovascular fitness and muscle endurance and finally f) to re-establish function and independence.

0-4 WEEEKS: In the initial month after the ORIF surgery, the physiotherapy programme will include exercises that aim to gradually introduce the patient to gentle activities. Along with this, the importance of amintaining strength and range of movement on the opposite knee dor essential support. The physiotherapy includes a) pain killers to control pain b) foot elevation to control swelling c) Assisted passive range of movement exercises d) Active range of motion on the fractured knee e) strengthening and range of movement on the unaffected knee.

5-8 WEEKS: During the second month onwards, the physiotherapy will focus on the continuation and progression of activities from previous weeks. GOALS: To control pain and swelling, improving range of movement and flexibility along with increasing muscle strength and control. The physiotherapy programe includes a) passive and active range of motion exercises b) gentle strengthening exercises on the affected knee c) range of motion, strengthening and stretching exercises on the unaffected arm d) mobilisation e) abduction, adduction and plantar flexion exercises e) hydrotherapy and f) cycling.

9-12 WEEKS: In the third month of rehabilitation focus on the continuation of exercises from previous weeks. The main aim is to reduce pain, improve strength and range of motion in the affected site. The physiotherapy programe inclues a) pain control b) range of motion exercises c) flexibility exercises d) passive stretching programe with combined movement e) strengthening exercises on the affected and unaffected fractured bone f) hand grip strengthening exercises g) hydrotherapy and h) cycling.

3 MONTHS ONWARDS: Following 3 months of successful rehailitation, the pain reduce which indicates marked improvements in the function and strength of the affected bone. The main goal after 3 months will continue to progress on the exercises from previous weeks. Cardiovascular activities such as hydrotherapy, cycling, jogging and even cross-training can be included to improve fitness.