Case -AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSED REDUCTION

Essay

Case
-AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSED REDUCTION
LOCATION: Outpatient, Hospital
PATIENT: Kelli Klarkor
SURGEON: Mohomad Almaz, MD
DIAGNOSIS: Displaced fractured base, left first
metacarpal
PROCEDURE PERFORMED: Closed reduction of metacarpal fracture
INDICATION: Kelli is a 15-year-old girl who fell while roller blading. She has now fractured her left thumb and will need manipulation to put it back in place. I have recommended a closed reduction and thumb spica cast application. The mother agrees with this.
PROCEDURE: Under a satisfactory level of sedation, the fracture was carefully manipulated and a well-padded and very well-molded fiberglass cast was placed over the base of the thumb. After this was applied, we applied repeat mini C-arm views and confirmed improvement in position of the fracture but still not in anatomic position.
Where it is presently, if it heals, it still will be completely functional. I reviewed this with the mother, and I have recommended that we cast this and re-manipulate it as the swelling goes down, and we will do this sometime next week.
T8.1:
SERVICE CODE(S): 26607-FA______________
ICD-10-CM DX CODE(S): S62.399A________
INCORRECT/MISSING CODE(S): ________________________________________