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Assign the ICD-10-CM code(s) to diagnoses and conditions and assign the CPT surgery code(s) and the...

Assign the ICD-10-CM code(s) to diagnoses and conditions and assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). Do not assign ICD-10-CM external cause codes.

PREOPERATIVE DIAGNOSIS: Displaced medial epicondyle fracture, left elbow.

POSTOPERATIVE DIAGNOSIS: Displaced medial epicondyle fracture, left elbow.

OPERATION PERFORMED: ORIF, left medial epicondyle fracture. (Initial encounter)

After IV sedation was started, the patient was brought into the operating room and placed supine on the table. Once an adequate level of anesthesia was obtained, the patient was taken out of the splint. He was noted to have significant swelling and instability with valgus stress to the elbow. The tourniquet was placed about the left proximal arm. The arm was exsanguinated. The tourniquet was inflated to 300 mmHg. A curved incision was done down the the medial aspect of the elbow and through the fascia. The elbow joint was entered. The medial epicondyle was completely avulsed and pulled distally. The fracture's edges were derided of hematoma. The medial epicondyle was grasped with a towel clip, and the elbow was flexed. Another guidewire was placed to control rotation. A 4.5 cannulated screw was placed across the fracture site plane, obtaining anatomical reduction. X-rays showed excellent position of both AP and lateral views. The guide pin was removed. The fracture was very stable. The wound was irrigated and closed with 2-0 Vicryl and skin staples. Sterile dressings were applied. The patient was placed in a long-arm posterior splint, well-padded with the elbow at 90 degrees. The patient tolerated the procedure well and was taken to the recovery room in good condition.

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Answer #1

ICD-10-CM code of Displaced medial epicondyle fracture, left elbow is S42.442

CPT code of Displaced medial epicondyle fracture, left elbow is 24575

HSPCS level - III for open surgery

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