Question

Operative Report

PREOPERATIVE DIAGNOSIS : Comminuted left proximal humerus fracture.

POSTOPERATIVE DIAGNOSIS : Comminuted left proximal humerus fracture.

OPERATIVE PROCEDURE : Open treatment of left proximal humerus.

ANESTHESIA : General.

IMPLANTS : DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.

INDICATIONS : The patient is a 66-year-old female who sustained a traumatic severe comminuted proximal humerus fracture. The risks and benefits of the surgical procedure were discussed. She stated that she understood and desired 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 she was prepped and draped in the usual sterile fashion in beach chair position after administering general anaesthesia. The standard deltopectoral approach was used. The cephalic vein was taken laterally with the deltoid. Dissection was carried out down to the fracture site and the fracture was identified. The fragments were mobilized and the humeral head fragments were removed. Once this was done, the stem was prepared up to a size 10. A trial reduction was carried out with the DePuy trial stem and implant head. This gave a good range of motion with good stability. Sutures down to and through the shaft were placed in key positions for the closure of the tuberosities. The shaft was prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and then reduced. A bone graft was placed around the area where the tuberosities were being brought down. The tuberosities were tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with vicryl over a drain and staples in the epidermis. A sterile dressing and sling were applied. The patient was taken to recovery in stable condition. There were no immediate complications.

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

Answer 1

The CPT code for the described surgery is 23615, and the ICD-10-CM code for the presented preoperative and postoperative diagnosis is S42.202A.

Step-by-step explanation:

For the operative report provided, the correct CPT (Current Procedural Terminology) code for open treatment of the left proximal humerus fracture with an implant is 23615. This code represents an open treatment of a proximal humeral fracture with a plate/screws, with or without cerclage. As for the ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) code, it would be S42.202A for an unspecified fracture of the upper end of the left humerus, initial encounter for the closed fracture.

These codes are used to describe the surgical procedure and fracture diagnosis and are crucial for medical billing and documentation. Due to the specificity of the codes, it is important for healthcare professionals to accurately report based on procedural details provided in operative reports.