PATIENT: HICKS, LOTTIE ACCOUNT/EHR #: HICKLO010 Pre/Post-op Diagnosis: Hallux limitus,…

PATIENT: HICKS, LOTTIE ACCOUNT/EHR #: HICKLO010 Pre/Post-op Diagnosis: Hallux limitus, right foot Operation: Shortening, osteotomy, first metatarsal, right foot, with screw fixation and cheilectomy, first metatarsal head, right foot Surgeon: Allen Roberston, DPM Anesthesia: IV sedation with local anesthesia DESCRIPTION OF PROCEDURE: Following the customary sterile preparation and draping, the right limb was elevated approximately 5 minutes in order to facilitate circulatory drainage, at which time the pneumatic cuff, which had previously been placed on her right ankle, was inflated to a pressure of 250 mmHg. The right limb was then placed in the operative position. The operative site was injected with 2% Xylocaine mixed with 0.5% Marcaine. Upon having achieved anesthesia, a curvilinear incision was created on the plantar medial aspect of the first metatarsophalangeal joint of the right foot. The incision was deepened with sharp dissection; traversing veins were cauterized. Capsule was identified on the medial and dorsomedial aspect. Capsule was longitudinally incised on the dorsomedial aspect and meticulously dissected to expose the head of the first metatarsal into the operative site. At this point, it was noted that the cartilage of the first metatarsal head was healthy; however, there was distinct irritation to the dorsal portion of the metatarsal head with an apparent flattening of the metatarsal head secondary to the hallux limitus. Using a rongeur, the hypertrophic exuberant portion of the first metatarsal head was resected, and the remaining surface was rasped smooth in order to recreate a ball joint. Using an oscillating saw, an osteotomy was performed from medial to lateral in a V-shaped fashion with the apex centrally located and the dorsal arm longer than the plantar arm. A segment of bone was removed from the dorsal arm in order to shorten and plantar flex the metatarsal head. Upon having done so, two 2.0-mm screws were obliquely driven into the osteotomy site; following range of motion was noted that the osteotomy remained stable. At this point, the hallux had approximately 90 degrees of motion to the metatarsal shaft. The area was copiously irrigated with sterile saline. The capsular tissue was repaired using 4-0 Vicryl; subcutaneous tissue was repaired using 5-0 Vicryl. Operative site was injected with dexamethasone, Betadine-soaked Adaptic was applied to the incision site, then sterile gauze and Kling. The pneumatic cuff was deflated. Normal color, circulation were noted to return to all digits immediately. The patient tolerated the surgery well. Vital signs remained stable throughout the entire procedure. The patient returned to the recovery room in good condition. Answer 1: Diagnosis Code Answer 2: CPT code with modifier Answer 3: CPT code with 2 modifiers