The report below describes a patient undergoing surgery for excision of left olecranon bursa and left medial epicondylar release. The entire procedure has been documented in detail, describing the step-by-step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed.
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- Anesthesia: General
- Complications: None
- Estimated blood loss: Minimal
- Indications: See my notes from the clinic
Technique: The patient was brought into the operative room and appropriate time-out was taken. I had initialed his elbow preoperatively. He was given intravenous antibiotics. At this time, I elected to make an approximate 5 cm curvilinear incision medially over the elbow. I carefully dissected down, preserving medial branches of the cutaneous nerve, then carefully dissected over the large inflamed bursa. I removed it in total. I thoroughly lavaged out this wound and then through the same incision dissected up proximally and performed a limited release of the medial epicondyle. I longitudinally incised the origin of the flexor mass and then subperiosteally elevated this and removed the inflamed tissue and tendon here. I thoroughly lavaged this out and then oversewed this with 2.0 Vicryl. I then closed the wound in layers w/ 4-0 Vicryl, closing the skin with interrupted 4-0 nylon. I did not feel that a drain was warranted, and I felt that this went very well through a small incision.
At this time, the sterile dressings were applied. Patient was awakened and taken to the recovery room in good condition.
- The first CPT code is 24358- LT. This represents incising over the epicondyle for debridement with soft tissue and/or bone. In this case the physician incised the flexor mass, as well as inflamed tissue and tendon. Modifier LT is used to report the procedure done on the left side.
- The second CPT code is 24105-51-LT. Bursa is the slippery sac between the loose skin and bone. It is normally flat but can become inflamed. The physician excised the bursa sac. Both procedures were performed through a 5 cm curvilinear incision, making the procedures open. Modifier 51 is used to report that a multiple procedure was performed. Modifier LT is used to report the procedure was performed on the left side.
- The ICD 10 CM diagnosis code is M77.02 M70.22. This patient had medial epicondylitis, an inflammation of the epicondyle on the inside of the arm. Look in the ICD 10 Alphabetic index for Epicondylitis/medial referring to you M77.0-This code requires a 5thcharacter to identify laterality.
This is also called golfer’s elbow when it is lateral. This patient also suffered from
olecranon bursitis. Look in the Alphabetic Index for Bursitis/elbow/olecranon referring you to M70.2-. This code also requires a 5th character to identify laterality.
**AAPC COSC Orthopedic Manual 2020