Clinical Documentation: Patient: Liza Martinez DOB: 01/03/1999

Clinical Documentation: Patient: Liza Martinez DOB: 01/03/1999 Date of Service: 02/20/YYYY Operative Report Preoperative Diagnosis: Left distal femur osteosarcoma Postoperative Diagnosis: Left distal femur osteosarcoma Operation: 1. Resection of left distal femur Prosthetic reconstruction of the left knee Osteotomy of the left femur Femoral artery exploration Anesthesia: General Estimated Blood Loss: 500 ml. The patient received four units of packed RBCs. Complications: None Indications for Procedure: the patient is a 25-year-old female who was diagnosed with a left distal femur osteosarcoma on biopsy and has undergone preoperative chemotherapy. Risk, benefits, complications, and alternatives of resection and reconstruction were discussed with her, and consent was obtained. Description of Procedure: the patient was seen in the preoperative area and a history and physical examination were performed. Consents were reviewed. She was taken to the operating room and given general anesthesia. She received preoperative antibiotics, and a Foley catheter was placed. Both legs were prepped and draped out. And external incision was made on the anterior medial aspect of the left thigh, extending towards the anterior aspect of the proximal tibia, including excision of the previous biopsy track. Dissection was carried down to the subcutaneous tissue leaving a cuff of healthy tissue on the biopsy track, and also a cuff of muscle was left. Dissection was carried subvastus, elevating the muscle but leaving the fat and other loose tissue including fascia on the tumor. Medially the vastus medialis was elevated off the medial septum. Dissection was carried further subvastus as wall as laterally. The Patella was preserved. Distally the subpatellar tendon fat pad was left with the need to be respect. Following dissection, and osteotomy site was located further laterally and approximately at 6 centimeters from the articular surface of the former condyle. This was based on the most recent MRI. An osteotomy was performed, parts of the posterior cortex were curetted, and marrow was removed and passed off to the pathologist for evaluation. Both of these were read on frozen sections as being normal and not containing any malignant tissue. With these findings known, the remaining posterior attachments to the femur were dissected. The femoral artery extending towards the popliteal space was carefully explored and retracted, and any branches of the tumor were either clipped or suture ligated. The tumor was dissected, and the reception was carried out under tourniquet at 270 mmHg. The tourniquet was let down and homeostasis was achieved with Bovie cautery, vascular clips, or suture ligations. The wound was slightly irrigated. The specimen was sent off to the pathologist for evaluation. The tibial surface was reamed, and trial implants were placed. The femoral canal was renamed to 15MM, which gave satisfactory chatter suggestive have a good fit. A 15 mm-diameter, 150 mm long stem was placed into the femur with various length trials. A regular femoral condyle was chosen along with a regular tibial component. Following adequate leg length, which gave use satisfactory soft tissue tensioning and rotation as well as the ability to close the wound and patella tracking, but also about 1 extra cm length on the left side, the appropriate components were chosen. The tibial plastic component was cemented into place. An uncemented 150 mm-long, 15 mm-diameter stem with the components in place was gently impacted into the femur and was checked under fluoroscopy. IT was noted to be satisfactorily placed. After placement of the brushings, the hinge, and the bumper, the components were reduced. The soft tissue tension was adequate, and the vessels seemed to be without any undue stress, and adequate pulsation of the femoral artery was present extending down to the popliteal space. With these findings, patella tracking was again checked and noted to be satisfactory. The wound was thoroughly irrigated, two drains were placed, and the various layers were reapproximated with either #1 Ethibond, #1, 0, or 2-0 Vicryl sutures, and then the skin was closed with 4-0 Monocryl. Steri-strips were applied, and the dressings were applied as well as the knee immobilizer with slight flexion of the knee. Postoperatively, the foot showed adequate blood flow with a palpable dorsalis pedis pulse. The patient was extubated. She will be admitted for postoperative pain control as well as rehabilitation and discharged when stable. SIGNED: Z, M. Hershey, MD Codes assigned by a Coder Level 1 at Sunrise General Hospital were D16.22, 27329, 76000 Audit Review: Address these questions in your written submission Do you agree with the assigned codes? If not, what codes would you assign and why? Provide the clinical documentation and/or coding guidelines to support your coding decision as an auditor?

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