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AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSED REDUCTION

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AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSED REDUCTION
AUDIT REPORT T8.1 OPERATIVE REPORT, CLOSED REDUCTION    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): ________________________________________ 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): ________________________________________


Definitions:

Levator Ani

A group of muscles situated in the pelvis that support the pelvic organs and assist in maintaining continence.

Pubococcygeus

A muscle of the pelvic floor that stretches from the pubic bone to the coccyx and is important for pelvic floor health and function.

Iliococcygeus

A muscle part of the pelvic floor that helps support the organs located in the pelvis.

Menarche

The onset of menstruation in girls, marking the beginning of reproductive capability.

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