What are the appropriate ICD-10-CM diagnosis codes and CPT procedure codes for this case? Please be specific with your answers
Preoperative Diagnosis: Subtalar joint degenerative joint disease, joint instability, chronic pan, and peroneal tendon atrophy
Postoperative Diagnosis: Subtalar joint degenerative joint disease and peroneal tendon at ophy
Procedure Performed: Subtalar joint fusion with external fixation device
Anesthesia: General
Materials: An Orthofix MiniRAIL with a total of 4 pins placed in the calcaneus and talus and ICOS screw from Integra. Trinity demineralized bone matrix from Orthofix.
Indications:
The patient is a 63-year-old male with degenerative joint disease, nontraumatic peroneal tendon atrophy, and has had problems with the left foot walking and standing. He did get into a custom AFO that has offered some relief. However, he is still experiencing joint instability and chronic pain.
Approach and Surgical Procedure:
The patient was brought in the operating room and placed in a supine position. General anesthesia was administered. Once adequate levels of anesthesia had been achieved, a time-out was called with the patient identification and the proposed procedure being agreed upon by the surgical team and operating room staff. The left foot was prepped and draped in the normal sterile fashion to include a pneumatic tourniquet placed about the left ankle.
Attention was directed to the lateral sinus tarsi region, where a 10 cm linear-type incision was made and deepened using blunt dissection. Bleeders were cauterized as necessary and neurovascular structures were retracted medially and laterally as necessary. Dissection was carried out using blunt and sharp technique revealing the subtalar joint. The capsule was incised, exposing the posterior and middle facets. Using an osteotome and mallet, the cartilage and subchondral plate were removed adequately to allow for eversion of the calcaneus, once fusion of the talus and calcaneus was achieved. The joint surfaces were prepared using a smaller osteotome for a shingling effect. At this time, Trinity demineralized bone matrix was introduced into the joint space. An ICOS screw was Introduced percutaneously through the dorsal aspect of the talar neck, This was placed through the neck and into the posterior aspect of the calcaneus. Under fluoroscopic guidance, it was noted that adequate compression of the subtalar joint was achieved. A MiniRAIL was then placed across subtalar joint. Two pins were placed in the calcaneus and two pins were placed in the body of the talus. Using the MiniRAlL
compression system, it was noted that the joint was further reduced. Incision was closed deeply, taking care to reattach the capsular structures, followed by reapproximation of the peroneal tendon sheaths, using Vicryl suture. Subcutaneous tissues were reapproximated using simple interrupted Vicry/ suturing. The skin was closed using a running locking Prolene suture. At this time, the surgical Site was dressed with Xeroform.
The patient was taken to the postoperative care unit where vital signs were stable and intact It was noted that neurovascular status of the left foot remained intact. Patient was discharged to home.
What are the appropriate ICD-10-CM diagnosis codes and CPT procedure codes for this case?
