1. Procedural Note Preoperative diagnosis: Possible malignancy

1. Procedural Note Preoperative diagnosis: Possible malignancy on muscle of left thigh After local anesthesia, a percutaneous bore needle was used to pierce the skin and fascia into the muscle to obtain a biopsy of the muscle tissue. The needle was removed with minimal blood. A bandage was placed on the site. The tissue sample was sent to pathology. The patient was in satisfactory condition after the procedure. CPT code(s): 2. This 84-year-old patient presented today for an injection with ultrasound guidance with permanent recording and reporting due to degenerative arthritis of the left hip. Procedure: After MAC sedation, the left hip was prepped. The puncture site was injected with 1% Lidocaine with epinephrine. A 20-gauge extra-long spinal needle was placed at the neck-head junction, and Isovue was injected. Additional injections of Lidocaine, Marcaine, and Depo-Medrol 80 mg were given. A Band-Aid was placed on the injection site. There were no complications of the procedure, and the patient was sent to recovery. CPT code(s): 3. Preoperative and postoperative diagnosis: Painful bunion of the right foot Operation performed: Correction of bunion—Silver bunionectomy After being placed in the supine position, the patient was prepped and draped. IV sedation with a local anesthesia consisting of 15 cc of 1:1 mixture of 0.5% Marcaine plain with 2% Xylocaine with epinephrine was administered. A 5-cm curvilinear incision was made over the first MPJ and carried deep through the subcutaneous tissue, with dissection down to the deep fascia. The prominent medial bunion was exposed, and the bunion was excised at the sagittal groove. The wound area was flushed with normal saline, and the deep structures were closed with 3-0 and 4-0 Vicryl. The skin was closed with 4-0 nylon in a horizontal mattress fashion. The wound was then dressed. The patient tolerated the procedure and was sent to the recovery area. CPT code(s): 4. Preoperative diagnosis: Mass on right middle finger, middle phalanx Pathology: Benign tumor from middle phalanx Operation: Excision of benign tumor of middle phalanx of finger The patient was prepped, and a digital block was achieved using 2.5 cc of 0.25% Marcaine and 1% Xylocaine. The finger was exsanguinated, and a tourniquet was placed. An incision was made over the mass and carried through the subcutaneous tissue. The mass was removed via curettes to scrape the mass from the bone. The specimen was labeled and sent to pathology. Irrigation of the wound occurred, and the skin was closed in layers. A sterile dressing was applied, and the patient was taken to the recovery area in stable condition. CPT code(s): 5. Procedural Note This patient presents with a subfascial soft tissue abscess for incision and drainage of the right upper arm. After local anesthesia was administered, an incision was made over the abscess on the right arm and continued down to the fascia until the abscessed area was visualized below the deep fascia. The deep abscess was viewed, debrided, and then drained. The area was irrigated, and packing was placed. The patient tolerated the procedure and was instructed to follow up with me in one week. CPT code(s): 6. Preoperative and postoperative diagnosis: Painful left index finger due to previous crush injury Procedure: Amputation of left index finger The patient was placed under general anesthesia, and a 1% Lidocaine and 0.5% Marcaine with epinephrine was administered to perform a digital block for the left index finger. A tourniquet was inflated on the left arm. An incision was made over the mid aspect of the proximal phalanx of the left index finger with dissection of the subcutaneous tissue. The digital nerves were cut, and then sharp dissection was taken down to the bone, dividing the flexor and extensor tendons. A bone cutter was used to divide the bone, and the finger was removed. The vessels and nerves were ligated, and the bone was smoothed off with a rongeur. The skin was closed with 5-0 nylon sutures and a dressing applied. The tourniquet was deflated. There was minimal blood loss, and the patient was taken to the recovery room in satisfactory condition. CPT code(s): 7. Diagnosis: Right radial shaft fracture Procedure: Open reduction internal fixation of radius The patient was placed in the supine position with an armboard extension. A nonsterile tourniquet was placed on the right arm. An incision was made proximal to the distal palmar crease and then extended to the level of the elbow crease through the subcutaneous tissue, until the flexor carpi radialis tendon was identified. Further dissection of the area revealed that the fracture was at the insertion of the FPL tendon. The fracture was reduced with bone forceps and clamps. A 12-hole DC plate was fitted to the normal curvature of the volar aspect of the radius. The plate was fixed to the shaft. The screw holes were filled, and there was adequate reduction of the radial shafting. Full supination and pronation were achieved. Hemostatis was achieved, and the wound was irrigated to remove all debris. The subcutaneous tissue was closed using 2-0 Vicryl sutures, and a 3-0 nylon suture was used to close the skin. Sterile dressings were applied, and the patient’s arm was placed in a sugar-tong splint. The patient was taken to the recovery room in good condition. CPT code(s): 8. Operative diagnosis: Carpal tunnel syndrome of the right hand Procedure: Endoscopic carpal tunnel release The patient was anesthetized with local anesthesia and IV sedation. After the patient was placed in the supine position, a tourniquet was placed on the right arm. A 1.5-cm horizontal incision was made at the wrist, and the subcutaneous tissue was dissected to gain entrance for the endoscope. The operative area was visualized on the monitor. The transverse carpal ligament was released. The scope was removed, and the wound was irrigated and closed with 3-0 Prolene in a running subcuticular stitch. Additionally, Steri-Strips and a sterile dressing were applied, and the tourniquet was deflated. Blood loss was minimal. Patient was stable and sent to recovery. CPT code(s) 9. Indication for surgery This 49-year-old female patient sustained a proximal tibial plateau fracture three years ago, which was repaired with both internal and external fixation. Since that time, she has developed significant pain due to degenerative disease in the previous fracture area. She presents today for hardware removal. Postoperative diagnosis: Retained hardware right knee Surgical procedure: Removal of hardware from right knee proximal tibia Procedure: The patient was placed in the supine position. The right leg was prepped and draped after the patient was placed under general anesthesia. High on the right thigh a tourniquet was placed, and the leg was exsanguinated using an Esmarch bandage. An incision was made and carried down through the skin and subcutaneous level down to the level of the hardware. Removal of the screws and plates occurred. The fracture was united at the time of closure. The wound was closed with staples and 2-0 Dexon. The patient tolerated the procedure and was taken to the recovery area. CPT code(s): 10. Preoperative and postoperative diagnosis: Left knee arthrosis Procedure: Arthroscopy and debridement The patient was prepped and brought into the operating room, where general anesthesia was administered. The knee was prepped, and a video arthroscopy was performed using the anterolateral and anteromedial portals. The scope confirmed the diagnosis. In the medial compartment, the degenerative meniscus was debrided with a shaver. The large osteophytes were removed with a bur. After removal, it was noted that there was improved extension. In the lateral compartment, a small anterior horn of the tear was debrided and shaved back to the meniscal tissue. The portals were sutured with nylon sutures. Sterile dressings were applied. The patient was in stable condition and was sent to the recovery room. CPT code(s):

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