Question

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS : Dislocation of the right elbow.

POSTOPERATIVE DIAGNOSIS : Dislocation of the right elbow with medial epicondyle fracture.

OPERATIVE PROCEDURE : Closed reduction of elbow dislocation with a closed reduction of medial epicondyle fracture.

ANESTHESIA : General.

INDICATIONS : This is a 12-year-old male who had an injury, sustaining a dislocation of his right elbow and medial epicondyle fracture. The risks and benefits of surgical treatment were discussed with the family, who stated they understood and wanted to proceed.

DESCRIPTION OF PROCEDURE : On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where general anaesthesia was induced. Once he was under adequate anaesthesia, the reduction manoeuvre was performed. The elbow was reduced and was stable. Through a full range of motion, there was noted to be slight crepitus on the medial elbow and some mobility was felt in the medial epicondyle. Examination under C-arm imagery revealed a concentric reduction of the elbow, but with mildly unstable medial epicondyle fracture. When the elbow was held in the appropriate position, the medial epicondyle was well reduced in an acceptable position. It was elected to treat this non-surgically. A long arm splint was applied. The patient was awakened from anaesthesia and taken to recovery in stable condition with no immediate complications.

What are the CPT® and ICD-10-CM codes reported?

Answer 1

CPT codes for closed elbow reduction procedures can range from 24600 to 24605 for dislocations and around 24530 for medial epicondyle fractures, whereas ICD-10-CM codes may include S53.132A for dislocation and S42.421A for fracture.

Step-by-step explanation:

The student is asking for the CPT (Current Procedural Terminology) and ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes based on an operative report describing a closed reduction of a right elbow dislocation and medial epicondyle fracture. Without knowing the specific details such as fracture displacement and the exact methods used, we can suggest that CPT code for the closed treatment of the elbow dislocation without fracture might be in the range of 24600-24605, whereas the closed treatment of the medial epicondyle fracture could be 24530 or similar, depending on specifics.

The ICD-10-CM code for a postoperative diagnosis of elbow dislocation with medial epicondyle fracture might be S53.132A for the dislocation and S42.421A for the fracture, where 'A' denotes the initial encounter.