MS Humerus 1 slide19 - AAPC

[Pages:2]Documentation Dissection

PREOPERATIVE DIAGNOSIS: Right displaced supracondylar humerus fracture. POSTOPERATIVE DIAGNOSIS: Right displaced supracondylar humerus fracture |1|. PROCEDURE PERFORMED: Closed reduction and percutaneous pinning of right supracondylar humerus fracture |2|.

ANESTHESIA: Via general endotracheal anesthetic.

INTRAOPERATIVE COMPLICATIONS: None.

POSTOPERATIVE CONDITION: Good.

TOURNIQUET USED: None.

INDICATIONS: The patient is a 13-year-old athetoid cerebral palsy patient who is noncommunicative verbally, but communicates with gestures and body. He is nonambulatory, but he does use his upper extremities for scooting and mobilization. He apparently got his arm caught in a railing and his wheelchair tipped at school yesterday |3|, which led him to become severely agitated. He was initially taken to another hospital where X-rays were obtained and found to have supracondylar humerus fracture |4|. He was transferred to this hospital for definitive surgical care. The patient's mother speaks very good English. Risks, benefits, and alternatives were discussed with the patient and he signed consent willingly.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating theater and placed in supine position on the operating room table. A general endotracheal anesthetic was administered. Timeout was performed verifying the patient's identity and operative site. Preoperative antibiotics were administered. The right upper extremity |5| was prepped and draped in the usual sterile fashion. With the guidance of C-arm, a closed reduction was performed and we verified with AP, lateral, and columnar/oblique views of the elbow to ensure an adequate reduction |6|. We felt that we had restored both Hexion as well as the rotation component of the deformity and realigned the columns nicely and felt this was a reasonable reduction. Therefore, we placed 3 percutaneous 0.062 K-wires from the lateral condyle directed proximal medially |7|. We did not place a medial pin, but we did at the third lateral just because he is so active that we wanted to have at least 1 more point of fixation. We did not identify any intraoperative complications. The radiographs were graded and saved for PACS archive. The drapes were taken down after a sterile dressing was applied and a posterior splint. The patient will follow up in the fracture clinic in 1 weeks' time for splint removal and placement of a long-arm cast. No intraoperative complications identified. Postoperative sponge, instrument, and needle counts were correct.

_____________________________________________________________ |1| Post-operative diagnosis is used for your diagnosis. Verify that there are no changes from this by thoroughly reading the operative note. |2| Procedure performed is verified by reading the description of procedure to ensure that the appropriate code is selected. |3| This gives us indication for how this injury occurred. "Caught between the railing and his wheelchair". |4| Supports the accuracy of the diagnosis. |5| Confirms which arm was injured and treated. |6| Confirms that a closed reduction was performed. |7| Placement of the K-wires for the percutaneous pinning.

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What are the CPT? and ICD-10-CM codes reported? CPT? Code: 24538-RT ICD-10-CM Codes: S42.411A, W23.1XXA Rationales: CPT?: This is a closed reduction with percutaneous pinning of a closed supracondylar fracture of the right humerus. Three K-wires were placed using fluoroscopy and a posterior splint was placed. Look in the CPT Index and look for Fracture/Humerus/ Supracondylar/Percutaneous Fixation and you are directed to 24538. Services included in this procedure are the fluoroscopy, and the splint application. Refer to the CPT guidelines for percutaneous skeletal fixation at the beginning of the Musculoskeletal Section for instructions. HCPCS Level II modifier RT is used to indicate the right humerus. ICD-10-CM: In the ICD-10-CM Alphabetic Index look for Fracture, traumatic/humerus/lower end/supracondylar/displaced which directs you to S42.41-. ICD-10-CM Official Guideline 1.C.19.c. indicates a fracture not indicated whether displaced or not displaced should be coded as displaced. The Tabular List verifies S42.41 is used for Simple supracondylar fracture without intercondylar fracture of the humerus. A sixth character is required to indicate laterality and a seventh character extender for the type of encounter. Code S42.411A is used for Displaced simple supracondylar fracture without intercondylar fracture of l right humerus, initial encounter for closed fracture. Look in the ICD-10-CM External Cause of Injuries Index for Caught/between/objects/stationary and you are directed to W23.1-. In the Tabular List a 7th character extender is required for the type of encounter. 7th character A is selected for the initial encounter. This is considered an initial encounter because it is active treatment of the injury, in which the patient is having surgical treatment. Two placeholder Xs are used to keep the A in the 7th position. The correct code is W23.1XXA. The place of occurrence, activity code, and external cause status codes are only reported once. This patient was transferred from another hospital. The initial hospital will report these codes and they will not be reported for this visit.

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