CPC sample question # 6
The following information is for CPT code for carpal tunnel release.
Preoperative Diagnosis: Left carpal tunnel
Postoperative Diagnosis: Same
Anesthesia: Bier Block.
Procedure Performed: Left carpal tunnel release; median epineurolysis.
Findings: Median nerve was adherent but no masses.
Indication: This has documents carpal tunnel syndrome based on electromyelogram.results and desires elective release.
Procedure: The patient was tacken to the operating room, positioned supine on the operating room table, and anesthesia was administered. The limb was prepped and draped in sterile fashine. The limb was elevated using a compressive bandage and the tourniquet was inflated to 225 mm Hg. The gauge was tested for oscilation. Local infiltration with 1 percent Xylocaine into the medial and ulnar position were performed.
An incision was made deep through the subcutaneous tissues. Bleeding points were electro-coagulated using bipolar cautery and the skin edges were handled atraumatically. The palmar fascia was identified and incised and the transverse carpal ligament was exposed. A wide release was achieved by opening its ulnar-most aspect and carrying the dissection distally to crossing the ulnar neurovascular bundle and proximally under vision in the antebrachial fascia of the forearm. The median nerve was adherent and an epieurotomy was carried out. The thenar branch was carefully protected and the wound was irrigated carefully. Hemostasis was achieved and closure was accomplished with 5-0 nylon sutures applied to the skin to ensure good coaptation of the skin edges. A sterile compressive dressing was applied with antibiotic-laden, nonadherent gauze. A volar cock-up wrist splint was applied with the thumb and digits free and the wrist in a moderate dorsification position.
All sponge, needle, and instrument counts were correct. There were no operative complications. The tourniquet was deflated and the patient was returned to the recovery room in good condition. Estimated blood loss was less than 50 cc.
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