Question

Q: Need help to Code ICD-10 CM for the diagnoses (primary & secondary) and all the CPT code for the procedure for following outpatient surgery case with explanation

ORTHOPAEDICS HISTORY AND PHYSICAL

DATE OF CONSULT: 11/8/2013

PRIMARY CARE PHYSICIAN: Jody L. Mathie, M.D.

CHIEF COMPLAINT: Retained hardware left femur

HISTORY OF PRESENT ILLNESS: is a 9 year old accompanied by his parents for history and

physical examination. has a history of left femur fracture treated with closed reduction, flexible IM nail fixation performed at an outside hospital in The femur fracture has healed, and is now indicated for hardware removal.

Allergies:No Known Allergies

Past Medical History Diagnosis Date

•VSD (ventricular septal defect)

•FRACTURE OF RADIUS AND ULNA- 2007

• ENT OTHER 12/29/07

Other ENT, nasal trauma

•Ventricular septal defect 6/2012

Spontaneously closed

•Strep pharyngitis •Closed femur fracture 2/2013

Past Surgical History

Procedure Laterality Date •Dental surgery procedure •Open rx femur fx+intramed rod 2/10/2013 Fracture Treatment - Open

Family History

Problem Relation Age of Onset •Lipids Mother

very strong maternal family history early cardiac disease

Social History:

Smoking/Alcohol/Drug Use or Exposure: No

Social History Narrative

Lives at home with parents, siblings

Medications:

No current facility-administered medications on file prior to encounter.

No current outpatient prescriptions on file prior to encounter.

REVIEW OF SYSTEMS:

Constitutional: Negative

HEENT: Negative

Respiratory: Negative

Cardiovascular: Negative

Gastrointestinal: Negative

Genitourinary: Negative

Musculoskeletal: See history of present illness.

Hematology/Lymphatic: Negative

Immune/allergy/rheumatologic: Negative

Skin: Negative

Neurologic: Negative

Mental Health: Negative

I have reviewed, verified and personally updated the allergies, past medical, past surgical, family, social,

medications and ROS history. Reviewed 11/8/2013 WIV

PHYSICAL EXAM:

Vital Signs: BP 104/66 | Pulse 64 | Temp 37.0 | Resp 20 | Ht 137 cm | Wt 29.4 kg | SpO2 91%

General: appears healthy, well developed, well-nourished and in no acute distress

HEENT: Normocepahlic and atraumatic

Neck: there is full active range of motion

Chest: no increased work of breathing

Cardiac: peripheral pulses strong and equal

Abdomen: soft, non-tender

Skin: pink, warm, well perfused, no rashes

Musculoskeletal:

Upper extremities: Skin and vascular exam normal with no evidence of infection

Lower extremities: skin and vascular exam normal

Gait: normal

DATA/DIAGNOSTIC STUDIES:

Radiology studies independently visualized and are pertinent for retained IM flex nails left femur, femur fracture appears well healed.

24 hr labs: none

IMPRESSION: He is a 9 year old with retained hardware left femur, indicated for hardware removal.

PLAN:

I have discussed the case with the referring provider and the family and our plan is to OR for left femur hardware removal.

Post procedure ice, rest and elevation were dicussed.

Patient education regarding wound and/or cast care, and return to clinic precautions were discussed.

OUTPATIENT DISCHARGE SUMMARY

PATIENT NAME:

ADMIT: 11/8/2013

DISCHARGE:

ATTENDING: Chang, Franklin M.

REFERRING PHYSICIAN:

PCP: Jody L. Mathie, M.D.

PRINCIPAL OR FINAL DIAGNOSIS: Retained hardware left femur

PROCEDURE: Hardware removal left femur

SECONDARY DIAGNOSES:

STATUS OF PATIENT: Good.

FOLLOW UP: Ortho clinic in: 4 months with Frank Chang, MD

Post-Op Plan: Patient will be discharged to home after meeting Day Surgery discharge criteria

WB Status: WBAT, no high impact activity including running, jumping, twisting, or contact sports x6 weeks

X-RAYS ON RETURN: 1 view bilateral LE's hips to ankles for leg lengths

Instructions were given to the family regarding follow-up and care.

Brief Op Note

Date of Surgery: 11/8/2013

Surgeon(s) and Role:

* Chang, Franklin M. - Primary

* Tulk, Kristen N. - Physician Assistant

Procedure: Hardware Removal Im Rod (Nanci Nail/Rush Rod) - Left - Leg

Specimens: * No specimens in log *

* No implants in log *

Preoperative diagnosis: Closed fracture of shaft of femur [821.01]

Postoperative diagnosis: same

Findings: Retained hardware was removed intact without complication

Estimated Blood Loss: 5mL

Operative Report

DATE OF SURGERY: 11/8/2013

PREOPERATIVE DIAGNOSIS: Retained hardware left femur s/p IM nailing of a left femur fracture

POSTOPERATIVE DIAGNOSIS: Retained hardware left femur s/p IM nailing of a left femur fracture

TITLE OF PROCEDURE: Hardware removal left femur

ANESTHESIA: General anesthesia.

INDICATIONS AND HISTORY: is a 9 year old with a history of left femur fracture

treated with closed reduction, flexible IM nail fixation performed at an outside hospital in

The femur fracture has healed, and is now indicated for hardware removal. Patient is indicated for the above named procedures.

DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient's parents after explaining the risks, benefits and possible complications of the procedure. All their questions were answered and concerns addressed. The proper operative site(s) were marked in the preoperative holding area. The patient was transported by Anesthesia Service to the operating room and placed supine on the operating table. Excellent general anesthesia was then obtained. The appropriate extremity(ies) were prepped and draped in the usual sterile fashion with the limbs draped free.

Attention was first directed to the left leg. Following exsanguination of the leg, the tourniquet was inflated to 155mmHg. The ends of the rods were palpated at the distal femur both medially and laterally. Attention was first directed to the medial distal femur and a 2cm incision was made overlying the end of the rod and in line with the previous incision extended distally. With care to maintain hemostasis, sharp dissection was carried down through the skin, subcutaneous tissue, fascia and muscle to the level of the bone. The end of the rod was identified and cleared of soft tissue. Vice grips were used to secure the end of the rod and using a mallet the vice grips were impacted and the rod was successfully removed without complication. The wound was thoroughly irrigated and closed in layers with 2-0 PDS for the deep fascia and muscle, 3-0 PDS for the subcutaneous tissue in a running fashion and 4-0 Monocryl for the skin in a running subcuticular fasion.

Attention was then directed to the lateral aspect of the distal femur where the same procedure was performed in an identical fashion as described above. Dermabond was placed on both wounds followed by steri-strips and a sterile dressing. 10mL of 0.25% bupivacaine with epi were injected into each surgical site. Tourniquet was released. An ace wrap was then applied to the knee.

Patient was successfully awakened from general anesthesia and transferred to the PACU in good condition.

POST-OPERATIVE COURSE: Patient will be discharged home the same day. may weightbear as

tolerated, but will need to avoid risky activities such as contact sports, jumping, running for 6 weeks. will

follow-up in 4 months for leg length evaluation.

Answer 1

Primary diagnosis:
Retained hardware left femur
We can code ICD-10 -cm for presence of functional implant Z96.9(Approximate synonyms we can use for this code presence of retained hardware also)
Procedure: Hardware removal left femur
Removal of implant ,deep,other than humeral and glenoid prosthesis CPT code 20680
Description of procedure
Anesthesia service for closed femur procedure -01220(general anesthesia)
Anesthesia service should be coded in operative notes separately ..if there is any special ,service or equipment used it should be coded separately for the billing purpose..
Use HCPCS code for Bupivacaine injection used S0020
HCPCS is a health care common procedure coding system that represents procedures,supplies,products and service..
use cpt code for ace wrap used 29540