Michael.James927
Member
Hi Everyone: Working from home as a Medical Coder not sure how to code this one . Thanks in advance Michael.james927
OPS Procedure performed: Left Carpal Tunnel Release
Complications: None
Indication: This is a 58-year-old male with left carpal tunnel syndrome. He failed to respond to conservative treatment. After a discussion of the options and risks, he elected surgery.
Procedure: The patient was taken to the operating room. He underwent IV sedation. The planned incision was infiltrated with local anesthetic and then an incision was made beginning at the base of the proximal phalanx in line between the 3rd and 4th metacarpals and extending to but not across the wrist crease. I cut the subcutaneous tissue and then sectioned the transverse carpal ligament. I initially exposed the median nerve and completed a proximal transaction of the ligament and undermined the wrist crease. I then completed a distal transaction of the ligament. The nerve was purplish colored. I was able to see more pink healthy-appearing nerve both at the proximal and distal ends of the decompression. I was content the nerve was adequately decompressed. I irrigated with copious amounts of saline. Subcutaneous tissue was closed with interrupted 2-0 Vicryl. The skin was closed with running 3-0 nylon stitches. A bulky dressing was placed. The patient tolerated the procedure well without apparent complications. Sponge, instrument, and needle counts were correct. He was moving his hand well after the surgery.
OPS Procedure performed: Left Carpal Tunnel Release
Complications: None
Indication: This is a 58-year-old male with left carpal tunnel syndrome. He failed to respond to conservative treatment. After a discussion of the options and risks, he elected surgery.
Procedure: The patient was taken to the operating room. He underwent IV sedation. The planned incision was infiltrated with local anesthetic and then an incision was made beginning at the base of the proximal phalanx in line between the 3rd and 4th metacarpals and extending to but not across the wrist crease. I cut the subcutaneous tissue and then sectioned the transverse carpal ligament. I initially exposed the median nerve and completed a proximal transaction of the ligament and undermined the wrist crease. I then completed a distal transaction of the ligament. The nerve was purplish colored. I was able to see more pink healthy-appearing nerve both at the proximal and distal ends of the decompression. I was content the nerve was adequately decompressed. I irrigated with copious amounts of saline. Subcutaneous tissue was closed with interrupted 2-0 Vicryl. The skin was closed with running 3-0 nylon stitches. A bulky dressing was placed. The patient tolerated the procedure well without apparent complications. Sponge, instrument, and needle counts were correct. He was moving his hand well after the surgery.
