The following documentation is from the health record of a male patient with a hand injury.
Hospital Outpatient Surgery Services
Preoperative Diagnosis: Open fracture, shaft of the middle phalanx of the left small finger, on the oblique
Postoperative Diagnosis: Open fracture, shaft of the middle phalanx of the left small finger, on the oblique with disruption of collateral ligament and extensor tendon
Procedure: Irrigation and debridement, open reduction of fracture, repair of extensor tendon and lateral collateral ligament, left small finger
Indications: This 42-year-old man sustained this injury at his single-family home while using a powered hedge trimmer which slipped. The medial ligament, soft tissue, and skin are intact. Because of this wound, the patient was brought to the operating room today.
Description: Two grams of Ancef were administered prior to the start of the case. The patient was identified by site of surgery, by direct communication with the patient, and by consent form. Following induction of general anesthesia, the left upper extremity294was prepped and draped in the usual manner. A tourniquet was placed. Attention was first directed to the wound, and the margins of the wound were trimmed of devascularized tissue. There was a significant amount of debris in the wound. It was debrided of bone chips using the operating microscope and lavaged with 4 liters of Kantrex saline solution. Following this, the oblique fracture of the middle phalanx was approximated over a metal pin using fluoroscopic guidance. This provided excellent alignment of the fracture and appropriate positioning of the finger. The extensor tendon was repaired with acceptable extension being achieved. The lateral collateral ligament was repaired and the PIP joint was again stable. The wound was closed using 4-0 nylon suture, apposing his soft tissues. The tourniquet was released. Tourniquet time was 40 minutes. Vascularization appeared adequate. Sterile bandage of bacitracin, Adaptic, 2 × 2s, and a tube gauze bandage were applied. Estimated blood loss was minimal during the procedure.
Which of the following ICD-10-CM and CPT code sets is appropriate for this service?
S62.627A, 26756-F4, 13131-F4
S62.627A, W29.3XXA, Y92.017, Y93.H2, Y99.8, 26735-F4
S62.627B, S63.697A, S66.317A W29.3XXA, Y92.017, Y93.H2, Y99.8, 26735-F4, 26418-F4, 26540-F4-59 or XS, 11012
S62.627B, W29.3XXA, Y92.017, Y93.H2, Y99.8, 26756-F4, 26418-F4, 26540-F4, 11012
Answer is :
Third one. That is S62.627B, S63.697A, S66.317A W29.3XXA, Y92.017, Y92.H2, Y99.8, 26735-F4, 26418-F4, 26540- F4-59or XS, 11012.
Because alphabetic index is main term is Fracture. Some of the sub terms are finger, little, middle, phalanx.
B indicates open fracture.
S63.69 is indicates tendon injury.
S66.31 indicates strains, A alphabet indicates injury.
So the answer is third one.
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