Musculoskeletal system



Musculoskeletal system



Common musculoskeletal complaints are pain of the neck, knee, shoulder, elbow, wrist, hand, back, hip, ankle, and foot. Conditions commonly related to the musculoskeletal system are sprains, bursitis, tendonitis, dislocations, fractures, nerve entrapments (such as carpal tunnel syndrome), and gout. A physician who specializes in the diagnosis and treatment of musculoskeletal disorders is an orthopedist. An orthopedic surgeon is one who not only diagnoses and treats musculoskeletal disorders but also performs musculoskeletal surgical procedures, for example, repairs involving the placement of pins, wires, screws, cranial halos, spinal instrumentation, and other fixation devices. Reconstruction surgeries such as hip replacements and other joint replacements are now performed frequently. Endoscopic procedures are often used in the orthopedic specialty. Most major clinics would have orthopedic physician(s)/surgeon(s) on staff, and in other settings the orthopedic services would be provided by an orthopedist in independent practice. Orthopedic physicians frequently receive referrals from other physicians to consult on musculoskeletal conditions.



Arthrocentesis


Arthrocentesis is injection and/or aspiration of a joint and is a commonly used treatment for joint conditions (Figures 8-1 and 8-2). A needle is inserted into the joint to anesthetize it. Drugs such as Depo-Medrol (synthetic glucocorticoid) or cortisone can then be injected into the joint, or fluid can be withdrawn. Bundled into the arthrocentesis are the dual services of injection and aspiration. For example, 20610 is reported when a physician withdraws fluid from the knee joint and then injects Depo-Medrol into the knee joint. The drug injected would be reported separately with a HCPCS code. HCPCS J code (drug code) descriptions identify the drug by the generic name, not the brand name. When reporting the drug with a HCPCS code, it is necessary to translate the brand name into the generic name; this is when the cross-reference feature of the Table of Drugs will be useful. For example, if the medical record indicates a Depo-Medrol injection, the Table of Drugs entry for Depo-Medrol (brand name) refers you to the generic name of the drug, methylprednisolone acetate (J1020-J1040). A current medical drug reference is also often necessary to translate brand names into the generic names to locate the drug in the HCPCS manual.


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FIGURE 8–1  Arthrocentesis.

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FIGURE 8–2 Arthrocentesis. Orange areas are injection sites.

If image guidance was used during an arthrocentesis reported with 20600-20610, report the radiographic service separately with 77002, 77012, 77021, or 76942.


Injections into the tendon sheath or ligament, tendon origin or insertion, or muscle are reported with 20550-20553 and are reported one time per service visit when the same tendon sheath, tendon origin/insertion, or muscle is injected, no matter how many injections were placed in that specific sheath, origin/insertion, or muscle. If, however, a tendon sheath and a tendon insertion were injected, both injections are reported.



Use modifier -59 (distinct service) when reporting multiple injections during the same service visit to make it clear that documentation indicates that separate services were provided. The drug injected would be reported separately with a CPT or HCPCS code. If image guidance was used during an injection reported with 20550-20553, report the radiographic service separately with 77002, 77021, or 76942.



Fractures


Closed fractures are those in which the bone does not protrude outside the skin and usually include terms such as comminuted, compound, depressed, elevated, fissured greenstick, impacted, linear, simple, or spiral.


Open fractures are those in which the bone does protrude outside the skin and include terms such as compound, infected, missile, puncture, or with foreign body. If the documentation indicates both open and closed fracture terminology, assign an open fracture code. The type of treatment does not necessarily correlate to type of fracture; for example, an open reduction of a closed fracture—meaning that the closed fracture can be repaired by means of an open procedure. The terminology describing the type of fracture and the type of treatment must be carefully abstracted from the documentation to correctly report the fracture type.


ICD-10-CM: Fractures are reported with S codes based on the area of injury, such as injuries to the head, S00-S09 or fractures of the face bones, S02.


ICD-9-CM: Fractures are reported with codes from the range 800-829 based on the location, such as:



The codes within these categories are usually divided based on the location of the fracture and/or the type (open/closed).


Vertebral column fractures


ICD-10-CM: Vertebral column fractures are reported with S12, S22, S32. Spinal cord injury is reported separately in addition to the fracture code. If the injury was only of the spinal cord, the injury would be reported with one of these codes: S14, S24, and S34. Cervical fractures are reported with S12.1–A for a closed fracture, and S12.1–B for an open fracture. Multiple cervical fractures are reported individually for each vertebral fracture.


ICD-9-CM: Vertebral column fractures are reported with 805. The fracture codes report fractures either with or without mention of spinal cord injury. Cervical fractures are reported with 805.0 for a closed fracture and 805.1 for an open fracture. There are fifth digits 0-8 available for assignment to indicate the level as C1-C7, unspecified, or multiple cervical vertebrae involvement. Multiple cervical vertebrae fracture without mention of spinal cord injury is reported with one code for the multiple sites, 805.08.


Fractures of the rib(s), sternum, larynx, and trachea


ICD-10-CM: Fractures of the upper limbs (S42, S52, S62) are divided by the specific location, as are the fractures of the lower limbs (S72, S82, S92). All fractures reported with ICD-10-CM codes require a seventh character to indicate the episode of care, such as “A” for the initial encounter, “D” for subsequent encounter, or “S” for sequelae. Not all codes have the same seventh characters available for assignment. Turn to the Tabular of the ICD-10-CM to S82 and review all of the seventh characters available for assignment. Also, see instructions in the Official Guidelines for Coding and Reporting, Section I.A.4. and 5., for more specific instructions on episode of care.


ICD-9-CM: Rib, sternum, larynx, and trachea fractures are assigned to 807 based on the status of open/closed and specific location. There are fifth digits available (0-9) to indicate the number of ribs involved, such as 5 for fifth rib and 6 for sixth rib.



From the Trenchesimage


“Coders must investigate codes, modifiers, HCPCS codes, and more before a final decision can be made. It is never boring!”


NANCY



CASE 8-1   8-1A Orthopedic Consultation


CASE 8-1


Dr. Green sent Janelle Masche to Dr. Almaz, an orthopedic physician/surgeon, for an opinion regarding her right tennis elbow (epicondylitis), which is an overuse syndrome. The lateral epicondyle is the outside bony portion of the elbow where the tendons attach from the muscle to the elbow. Repetitive motion can injure the tendon, causing pain. X-rays are usually normal. Local cortisone may be injected.



8-1A  Orthopedic consultation


LOCATION: Outpatient, Clinic


PATIENT: Janelle Masche


PRIMARY CARE PHYSICIAN: Ronald Green, MD


CONSULTANT: Mohomad Almaz, MD


HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old woman who works in coding at the local hospital. Dr. Green referred her for right tennis elbow.


She explained that her right wrist started hurting about 6 months ago when she was pulling some charts. Then, about 4 months ago, she developed some pain along the lateral aspect of her right elbow. She saw Dr. Green and states that he treated her with an injection. I am unable to find evidence of this injection in the chart, but she explained that it was done probably in 1989. She has also been treated with a tennis elbow strap.


PHYSICAL EXAMINATION: The physical examination today finds that she localizes her pain to the lateral aspect of the right elbow near the lateral humeral epicondyle.


She has pain in the area with dorsiflexion of her wrist against resistance. She has a full range of motion of her right elbow, including supination and pronation. No areas of erythema are noted.


X-rays of her right elbow found the bony architecture to appear essentially within normal limits.


IMPRESSION: Right lateral humeral epicondylitis


RECOMMENDATION: I have elected to inject the tender area over the right lateral humeral epicondyle with 80 mg (milligram) of Depo-Medrol and 1 cc (cubic centimeter) of 1% Xylocaine following Betadine prep. I have asked that she let me know if she has further problems. She understands that a tennis elbow release may be necessary if the pain returns following these injections.



Fractures of the upper limbs (810-819) are divided by the specific location, as are the fractures of the lower limbs (820-829). There are also fifth digits available for many of the codes for ICD-9-CM.


External cause codes are only reported at the time of initial episode of care and only if the facility policy indicates that external cause codes will be assigned. If, as per facility policy, external cause codes are assigned, and since fractures usually are a result of an accident of some type, an external cause code would be assigned to indicate the way in which the accident happened (circumstances of the accident).



Fixation


Fixation can be internal or external and is used to hold a bone in place. Internal fixation is the placement of wires, pins, screws, plates, or rods onto or into the bone to repair bones. External fixation is the application of a device that holds the bone in place from the outside. Fasteners are driven into the bone percutaneously, and the external fixation device is attached to the fasteners. Percutaneous fixation (skeletal fixation) is a type of external fixation that serves as attachments for traction devices.


Both application and removal of the device are reported with one code. If a physician other than the physician who applied the device removes the device, the removal is reported separately. When reporting a fracture repair with the application of a fixation device, the device is usually reported separately; however, use caution when reporting the repair and application, because some fracture codes include application of devices in the code description (so then you would not report the services separately). Routine adjustment of the device is included in the application code unless the adjustment requires anesthesia.



CASE 8-2   8-2A Operative Report, Application of Halo


CASE 8-2


Dr. Almaz applies a cranial halo to stabilize a C1-C2 fracture, as illustrated in Figures 8-3 and 8-4. This is the initial treatment of the injury. Assign an external cause code/E code to indicate how the accident happened.


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FIGURE 8–3 A cranial halo device.

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FIGURE 8–4 Halo device.


8-2A  Operative report, application of halo


LOCATION: Outpatient, Hospital


PATIENT: Ella German


SURGEON: Mohomad Almaz, MD


PREOPERATIVE DIAGNOSIS: Fracture of C1 (first cervical vertebra) and C2 (second cervical vertebra)


POSTOPERATIVE DIAGNOSIS: Fracture of C1 and C2


PROCEDURE PERFORMED: Application of halo


PROCEDURE: The patient’s head was prepped and draped. The halo was applied to the head. Lidocaine was used in the area where the pins enter. We then placed the pins and fitted the patient with the rest of the vest. The patient is comfortable. She can get mobilized with the halo. She is 89 years old. You wonder whether she will ever heal after this fall. We will keep her in the halo for 3 to 4 months and see if she heals properly.




CASE 8-3   8-3A Operative Report, Hardware Removal


CASE 8-3


Removal of hardware is not included in the insertion procedures when the procedure is performed outside the global period, as in this case in which the hardware was placed last year and is being removed now and reported separately. Code the removal service in the following case. (Remember to report the diagnosis with an ICD-10-CM fracture code, indicating aftercare with a seventh character for subsequent care and an ICD-9-CM V code for fracture aftercare.)




8-3A  Operative report, hardware removal


LOCATION: Outpatient, Hospital


PATIENT: Gary Leiser


SURGEON: Mohomad Almaz, MD


PREOPERATIVE DIAGNOSIS: Healed comminuted fracture, right distal radius


POSTOPERATIVE DIAGNOSIS: Healed comminuted fracture, right distal radius


NAME OF OPERATION: Removal of hardware, right distal radius


INDICATIONS FOR SURGERY: This patient had a traumatic distal radius fracture treated last year with a Synthes dorsal distal radius plate. Because of the risk of atraumatic rupture of the extensor tendons running over the plate, it was elected to remove the plate at this time.


OPERATIVE PROCEDURE: After a suitable general anesthesia was achieved, the patient’s right wrist, hand, and forearm were prepped and draped. Before prepping, an arm tourniquet was applied and, after draping, inflated to 250 mmHg (millimeter of mercury). Scar on the dorsal aspect of the wrist was used as the site of the incision. The extensor pollicis longus tendon was incised in line with the tendon. The tendon was then retracted. The extensor retinaculum was elevated off at the plate bone level. The plate was then easily exposed. Screws were removed, and the plate was easily elevated. The wound was then irrigated. Skin edges were infiltrated with 0.5% Marcaine with adrenaline. The retinaculum was closed with 2-0 Tycron, subcutaneous tissue with 3-0 Vicryl, and the skin with interrupted 4-0 nylon horizontal mattress sutures (this indicates the plate removal was from “deep” layers). The patient tolerated the procedure well and returned to the recovery room in stable condition.




Excision


Throughout the Musculoskeletal System subsection, there are excision codes. These codes are used to report excisions from the deeper levels. Recall that excision codes are also located in the Integumentary System subsection. It is the origin of the excision that differentiates the codes. For example, if a superficial benign lesion was removed from the skin of the leg, the service is reported with a code from 11400-11406 (Integumentary System). If the excision was of a lesion located on the muscle of the leg, the service is reported with 27619 or 27634 (Musculoskeletal System), depending on the size of the tumor (<5 cm, >5cm). Watch for terms that indicate the origin of the neoplasm, such as melanoma (skin) or sarcoma (connective tissue) to direct you to the correct code selection.



CASE 8-4   8-4A Operative Report, Preauricular Area Excision


CASE 8-4



8-4A  Operative report, preauricular area excision


LOCATION: Outpatient, Hospital


PATIENT: Doris Fisher


SURGEON: Mohomad Almaz, MD


PREOPERATIVE DIAGNOSIS: Malignant melanoma, skin of left preauricular area


POSTOPERATIVE DIAGNOSIS: Malignant melanomas with clear margins on the skin of the left preauricular area


PROCEDURE PERFORMED: Wide excision (this indicates radical excision) of malignant melanoma, skin of left preauricular area


ANESTHESIA: General endotracheal with supplementary 1% Xylocaine with 1:800,000 epinephrine


ESTIMATED BLOOD LOSS: Approximately 25 cc (cubic centimeter)


PROCEDURE: The patient’s left face and ear were prepped with Betadine scrub and solution and draped in a routine sterile fashion. The 0.8-cm lesion was excised to include the crus of the left ear in the dissection, because this was the only method to provide at least 2 cm (centimeter) of width around the excision site. We were able to get about 2.5 cm on the anterior excision site and at least 3 cm proximally and distally. We submitted the specimen, tagging the superior aspect with a silk suture, and cauterized the bleeding. A small section of the fascia and muscle was repaired, and then, using separate instrument and gloves, we undermined the skin after the manner of a subcutaneous facelift and brought the skin up, suturing it to the more posterior edge with interrupted 3-0 Prolene. We dressed the wound with Xeroform, Kerlix fluffs, and a Kerlix roll plus Kling. The patient tolerated the procedure well and left the operating table in good condition.


Pathology Report Later Indicated: Malignant melanoma




CASE 8-5   8-5A Operative Report, Carbuncle Removal


CASE 8-5


Not all deep tissue excisions are reported with Musculoskeletal System codes. For example, the services in the next two cases are reported with Hemic and Lymphatic Systems codes. Note the two diagnoses highlighted in this report. This is another good example of why a coder must read the report and not code from the Postoperative Diagnosis section of the report.




8-5A  Operative report, carbuncle removal


LOCATION: Outpatient, Hospital


PATIENT: Jennifer Carlin


PRIMARY CARE PHYSICIAN: Ronald Green, MD


SURGEON: Gary Sanchez, MD


PREOPERATIVE DIAGNOSIS: Two separate carbuncles, left axilla


POSTOPERATIVE DIAGNOSIS: Two separate carbuncles, left axilla


PROCEDURE PERFORMED: Removal of two separate carbuncles, left axilla. Tissue was submitted for aerobic and anaerobic cultures as well as permanent section.


INDICATION: This patient for the last 6 months has had a couple of carbuncles in her left axilla. They have been observed, and she has been placed on antibiotics. Attempts at drainage have been made, however, without results. Finally, the patient wants to have these tumors removed.


PROCEDURE IN DETAIL: After good MAC, the patient was prepped and draped in the usual sterile fashion. The left arm was adducted to expose the axilla. The two areas were infiltrated separately with 1% lidocaine after the incisions were made over both affected areas, and dissection was carried down to encompass subdermal and deeper tissue. An inflamed lymph node was also identified, and this was taken with the more superficial tissue. After this, the wounds were irrigated and closed with 4-0 subcuticular stitch. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was returned to the recovery room in good condition.


Pathology Report Later Indicated: Lymph node was negative for neoplastic behavior.




CASE 8-6   8-6A Operative Report, Dissection and Excision


CASE 8-6



8-6A  Operative report, dissection and excision


LOCATION: Outpatient, Hospital


PATIENT: Sara Henre


PRIMARY CARE PHYSICIAN: Ronald Green, MD


SURGEON: Gary Sanchez, MD


PREOPERATIVE DIAGNOSIS: History of palpable right axillary mass


POSTOPERATIVE DIAGNOSIS: History of palpable right axillary mass


OPERATIVE PROCEDURE: Superficial right axillary dissection and excision of lymphatic tissue, 2.9 cm


COMPLICATIONS: None


ESTIMATED BLOOD LOSS: 50 cc (cubic centimeter)


ANESTHESIA: General endotracheal with 30 cc of 0.5% Marcaine augmentation


SPECIMEN: Superficial axillary contents. 1.8-cm mass was identified.


PROCEDURE: After good general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion. The arm and axilla were prepped, and the hand and forearm were covered with a stockinette to allow mobilizing. The patient was previously interviewed in the preoperative area, and the palpable mass had been marked with ink. An incision was made over this area, which was in the axillary skin fold just above the axillary hairline, and this was after anesthetizing the skin. Dissection was carried down right under the skin in search of this nodule. We did find a 1.8-cm mass that represented a small lipoma in this area. This was resected. The axillary fascia was identified and incised, and similar fatty tissue was excised upward at the border of the latissimus and then down toward the posterior border of the axilla. An exploring finger was placed up in the axilla up toward the axillary vein, and no palpable adenopathy was noted, nor was there any adenopathy noted when the rest of the axilla was explored with a finger. We did continue to take away small pieces of lymphatic tissue in the entire area where the patient felt the lump and submitted this as axillary fatty and lymphatic contents. The wound was thoroughly irrigated. Bleeding was controlled using electrocautery. The wound was then closed in layers with 3-0 Vicryl and 4-0 Vicryl subcuticular. The patient tolerated the procedure well and was returned to the recovery room in good condition.


Pathology Report Later Indicated: Benign encapsulated lipoma (of subcutaneous breast)




CASE 8-7   8-7A Operative Report, Nevus Removal


CASE 8-7


A congenital nevus is a mole that is present at birth. There is a difference between a small and a giant nevus. Usually a giant congenital nevus is larger than 20 cm, and the small nevus is usually about 1.5 cm. In the CPT manual, the excision codes for nevus are based on the depth of subcutaneous or intramuscular and the size of the tumor.




8-7A  Operative report, nevus removal


LOCATION: Outpatient, Hospital


PATIENT: Earl Oukek


PRIMARY CARE PHYSICIAN: Ronald Green, MD


SURGEON: Mohomad Almaz, MD


PREOPERATIVE DIAGNOSIS: Giant congenital nevus, left pectoral region involving the left areola


POSTOPERATIVE DIAGNOSIS: Giant congenital nevus, left pectoral region involving the left areola


PROCEDURE PERFORMED: Excision of giant congenital nevus and portion of areola of the left chest


SURGICAL FINDINGS: A 7 × 4-cm (centimeter) giant congenital nevus (common nevus) involving about 50% of the areola on the left side


ANESTHESIA: General endotracheal plus 4 cc (cubic centimeter) of 0.5% Xylocaine and 1:100,000 epinephrine


COMPLICATIONS: None


SPONGE AND NEEDLE COUNTS: Correct


DESCRIPTION OF THE PROCEDURE: The patient’s chest wall was prepped with Betadine scrub and solution and draped in a routine sterile fashion. I injected 4 cc of 0.5% Xylocaine with 1:100,000 epinephrine along the suture line and excised the lesion down to carpus fascia being sure to include the complete dermis and a little subcutaneous fat. We cauterized the bleeders and tagged the superior aspect of the specimen with a silk suture. We closed the wound with subcuticular 3-0 Monocryl and three twists of 6-0 Prolene. One-half-inch Steri-Strips were applied, plus a clavicle strap for immobilization. Estimated blood loss was less than 5 cc. The patient tolerated the procedure well and left the operating room in good condition.


Pathology Report Later Indicated: Benign tissue (chest skin)




From the Trenchesimage


“Some of the benefits to working in medical coding are advancement, friends, education continues on a daily basis, and it rewards a job well done.”


NANCY



CASE 8-8   8-8A Operative Report, Costovertebral Tumor


CASE 8-8



8-8A  Operative report, costovertebral tumor


LOCATION: Outpatient, Hospital


PATIENT: Leif Hanson


PRIMARY CARE PHYSICIAN: Leslie Alanda, MD


SURGEON: Mohomad Almaz, MD


PREOPERATIVE DIAGNOSIS: Residual plexiform fibrous histiocytic tumor of left costovertebral angle area


POSTOPERATIVE DIAGNOSIS: Residual plexiform fibrous histiocytic tumor of left costovertebral angle area


PROCEDURE PERFORMED: Excision of plexiform fibrous histiocytic tumor (this is a mast cell tumor) of left costovertebral angle (this is connective tissue of the back) measuring 2.4 cm, and evacuation of hematoma (this is a postoperative hematoma), left costovertebral angle


ANESTHESIA: General endotracheal was with approximately 20 cc (cubic centimeter) of tumescent solution prepared by adding to 1L of Ringer’s lactate, 25 cc 2% Xylocaine, 1 cc of 1:100,000 epinephrine, and 3 cc of 8.4% sodium bicarbonate.


ESTIMATED BLOOD LOSS: Negligible


SURGICAL FINDINGS: There was a healing 2.5-cm (centimeter) incision of the left costovertebral angle, and in the subcutaneous space on top of the latissimus dorsi muscle, there was about a 50-cc hematoma that was beginning to organize.


DESCRIPTION OF PROCEDURE: The patient was intubated and turned in the prone position. The area of the left costovertebral angle was prepped with Betadine scrub and solution and draped in a routine sterile fashion. An incision was made 2 cm around in the previous incision site and carried down to the fascia of the muscle, where a hematoma was entered. The skin portion of that lesion (5.1 cm) was removed, and the fascia and a portion of the muscle of the latissimus dorsi were removed secondarily. Bleeding was electrocoagulated, and a no. 7 Jackson-Pratt drain was inserted in the depth of the wound. The wound was closed with interrupted 0 Monocryl for the deep fascia layer and subcuticular 4-0 Monocryl using a few vertical mattress sutures of 3-0 Monocryl. Steri-Strips and Kerlix fluffs plus Elastoplast were applied. The patient tolerated the procedure well and left the operating room in good condition.


Pathology Report Later Indicated: Mast cell tumor




CASE 8-9   8-9A Operative Report, Shoulder Mass Excision 8-9B Pathology Report


CASE 8-9



8-9A  Operative report, shoulder mass excision


LOCATION: Outpatient, Hospital


PATIENT: Verner Fox


SURGEON: Mohomad Almaz, MD


PREOPERATIVE DIAGNOSIS: Giant mass of right shoulder


POSTOPERATIVE DIAGNOSIS: Giant mass of right shoulder, probable lipoma


PROCEDURE PERFORMED: Excision of a giant shoulder mass. The mass was excised and measured 14 × 14 cm × 6 cm deep. This was found to be superficial to the trapezius fascia.


DRAIN: One Jackson-Pratt


PROCEDURE IN DETAIL: After good sedation, the area around the giant mass was anesthetized with a total of 60 cc (cubic centimeter) of 0.5% Marcaine with epinephrine. An incision was made along Langer’s line over the apex of the mass. Dissection was carried down through the skin down to the mass itself. Very large skin flaps were created in both directions measuring 6 inches and 6 inches. The mass was quite adherent, and any fibrous septa were dissected free to mobilize it. Eventually we were able to mobilize the bottom of the mass, and we were able to reflect it back from the fascia. We then dissected it free of its fascial attachments, going medially to laterally. We then removed it from the lateral attachments that were very close to the skin. After the mass was excised, the wound was thoroughly irrigated. Meticulous hemostasis was obtained with electrocautery. A no. 10 flat Jackson-Pratt drain was placed and brought out inferior to the wound. The wound was then closed in two layers with 3-0 Vicryl subdermal and 2-0 nylon mattress sutures. The drain was secured with 0 Prolene and placed to bulb suction. The patient tolerated the procedure well and was returned to the recovery room in good condition.


Pathology Report Later Indicated: See Report 8-9B.




8-9B  Pathology report


LOCATION: Outpatient, Hospital


PATIENT: Verner Fox


SURGEON: Mohomad Almaz, MD


PATHOLOGIST: Morton Monson, MD


CLINICAL HISTORY: Right shoulder mass


SPECIMEN RECEIVED: Right shoulder mass


GROSS DESCRIPTION: The specimen is labeled with the patient’s name and “right shoulder mass” and consists of a 635-gm globulated mass of adipose-like tissue. The exterior surgical margins are inked in black. The mass is approximately 14 × 14 × 6 cm (centimeter) in thickness. Cut sections show adipose tissue throughout. Representative sections are submitted in 13 cassettes.


MICROSCOPIC DESCRIPTION: Sections show adipose throughout, intersected by fine strands of fibrous tissue.


DIAGNOSIS: Right shoulder mass: benign lipoma




CASE 8-10   8-10A Operative Report, Tumor Excision


CASE 8-10



8-10A  Operative report, tumor excision


LOCATION: Outpatient, Hospital


PATIENT: Ervin Gulman


SURGEON: Mohomad Almaz, MD


PREOPERATIVE DIAGNOSIS: Malignant melanoma, left shoulder (6 cm [centimeter])


POSTOPERATIVE DIAGNOSIS: Malignant melanoma, left shoulder (6 cm [centimeter])


PROCEDURE PERFORMED: Radical excision of malignant melanoma, posterior aspect of skin of left shoulder


ANESTHESIA: General endotracheal with supplementary 1% Xylocaine with 1:100,000 epinephrine, approximately 10 cc (cubic centimeter)


ESTIMATED BLOOD LOSS: Negligible


PROCEDURE: The shoulder was prepped with Betadine scrub and solution and draped in the routine sterile fashion. A margin of about 3 cm (centimeter) laterally and medially around the healed incision site was taken, tapering to 4 to 5 cm proximally and distally. The incision was carried down into the muscle fascia, which was included with the specimen. Bleeding was electrocoagulated, and the wound was closed with subcuticular 2-0 Monocryl and some twists and pulley sutures of 2-0 Monocryl in the center of the wound, where the most tension was. Kerlix fluffs and a sling were applied followed by an external Ace bandage. The patient tolerated the procedure well and left the area in good condition.


Pathology Report Later Indicated: Malignant melanoma of shoulder (this is an upper limb)




CASE 8-11   8-11A Operative Report, Ganglion Cyst


CASE 8-11



8-11A  Operative report, ganglion cyst


LOCATION: Outpatient, Hospital


PATIENT: Lilah Coan


SURGEON: Mohomad Almaz, MD


INDICATIONS FOR PROCEDURE: This patient has had a ganglion cyst of the second web space of the left hand just proximal to the web space but overlying the ulnar side of the A1 pulley (tendon on anterior surface of finger). It has become annoying and occasionally painful.


PREOPERATIVE DIAGNOSIS: Ganglion cyst, left index finger, with protrusion into second web space on the ulnar side


POSTOPERATIVE DIAGNOSIS: Ganglion cyst, left index finger, with protrusion into second web space on the ulnar side


PROCEDURE PERFORMED: Excision of ganglion cyst, left index finger


SURGICAL FINDINGS: A 1-cm (centimeter) diameter more or less dumbbell-shaped ganglion cyst of the left index finger arises from the ulnar side of the A1 pulley and extending into the base of the second web space.


ANESTHESIA: Intravenous block


ESTIMATED BLOOD LOSS: Zero


COMPLICATIONS: None


SPONGE AND NEEDLE COUNTS: Correct


PROCEDURE: Under satisfactory intravenous block anesthesia, the patient’s left hand and arm were prepped with Betadine scrub and solution and draped in the routine sterile fashion. Using 2.5-power magnification, two 1-cm-long Z-plasty flaps were marked out beginning at the central limb, which was situated over the site of the mass. After development of the flaps, dissection was carried down to the A1 pulley, which had a ganglion cyst arising from its surface more or less on the ulnar side and extending in an ulnar direction into the area of the base of the second web space. This cyst was dissected free intact. After completion of the ganglion removal and submission for permanent sections, we closed the wound with interrupted 6-0 Prolene sutures with Gillies sutures for the tips of the flaps. After cleaning Betadine off the hand and the arm, dressing consisted of Xeroform, Kerlix, several Kerlix fluffs, Kerlix roll, Kling, Sof-Rol, and an Ace bandage from the fingers to the elbow. The patient tolerated the procedure well and left the operating room in good condition.


Pathology Report Later Indicated: Ganglion cyst, benign




Repair, revision, and reconstruction


Most of the anatomic subheadings (e.g., Shoulder or Humerus [Upper Arm] Elbow) in the Musculoskeletal System subsection include a Repair, Revision, and Reconstruction category. The procedures are osteoplasty, osteotomies, arthroplasty, tendon transplants or transfers, and various other repairs, revisions, and reconstructive procedures with numerous grafting procedures for bones, tendons, and muscles. Be certain to identify the correct location and extent of the procedure before assigning a code. A good medical dictionary is an important tool as you report muscle repairs, as only by understanding all of the medical terminology in each report can you be certain to report the service accurately.



CASE 8-12   8-12A Operative Report, Rotator Cuff Repair


CASE 8-12


This report states that the reconstruction procedure was a repair with acromioplasty. An acromioplasty is the surgical removal of a portion of the acromion (the highest point on the shoulder) to relieve compression of the rotator cuff when the joint moves. The acromioplasty is bundled into the repair procedure and is not reported separately.




8-12A  Operative report, rotator cuff repair


LOCATION: Outpatient, Hospital


PATIENT: Casey Chaput


SURGEON: Mohomad Almaz, MD


PREOPERATIVE DIAGNOSIS: Left, nontraumatic, rotator cuff tear


POSTOPERATIVE DIAGNOSIS: Left, nontraumatic, rotator cuff tear


PROCEDURE PERFORMED: Repair of left rotator cuff repair with Neer acromioplasty


ANESTHESIA: General with endotracheal intubation


FINDINGS: The patient was found to have a complete tear of the rotator cuff. This extended from approximately the level of the long head of the biceps around posteriorly about 2 cm (centimeter).


We created an incision over the left acromion in a shoulder-strap fashion and dissected down through the subcutaneous tissue until we identified the acromion. We reflected the deltoid sharply off the anterior and anterolateral aspect of the acromion. We were then able to view the subacromial space, and we immediately noted a large tear in the rotator cuff. We were careful not to split the deltoid more than about 1 cm.


We then thought there was a rather prominent inferior corner to the anterolateral edge of the acromion. We elected to proceed with a Neer acromioplasty. We then removed the inferior corner of the anterolateral aspect of the acromion using an oscillating saw. We smoothed the undersurface of the acromion with a rasp. After thoroughly irrigating the area with saline, we were able to achieve a very nice view of the rotator cuff tear. We found that the rotator cuff had essentially split into two layers, and they were both avulsed from the humeral head from the long head of the biceps around the articular surface about 2 cm. We freshened the edges of the rotator cuff and then created a bony trough along the margin of the articular surface, starting from the long head of the biceps posteriorly about 2 cm. We then used two sutures of no. 1 Nurolon. We passed each suture through the proximal humerus and out through the bony trough. We then entered the rotator cuff and then again through the bony trough such that when we tied the sutures, the rotator cuff was pulled nicely into the bony trough. We thoroughly irrigated this area before we tied the sutures and then abducted the shoulder as the sutures were tied. Again, the rotator cuff was pulled nicely into the trough without undue tension. We then freshened the margins of the acromion and repaired the deltoid back to the acromion with no. 1 Panacryl suture. We closed the subcutaneous tissue using 2-0 Vicryl, and the skin was closed using 4-0 nylon suture. A sterile Xeroform dressing was applied. Then we placed the patient’s left arm into a sling with an abduction pillow to keep the arm abducted slightly. She was then taken from the operating room in good condition and breathing spontaneously. The final sponge and needle counts were correct. She was given 1 g of Kefzol intravenously preoperatively and will be continued on 1 g of Kefzol q.8h. for 2 days.


Pathology Report Later Indicated: Benign tissue and bone morsels


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May 17, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Musculoskeletal system

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