Get Answer: Preoperative Diagnosis Left Question Guide

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This question relates to preoperative diagnosis left and requires a structured academic response.

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Structure your response with introduction, analysis, and conclusion.

Key Explanation

This topic involves preoperative diagnosis left. A strong answer should include explanation, application, and examples.

Original Question

PREOPERATIVE DIAGNOSIS: Left femur hardware protrusion POSTOPERATIVE DIAGNOSIS: Left femur lateral hardware protrusion, status post medial and lateral Nancy nail trimming PROCEDURE PERFORMED: Left femur medial and lateral Nancy nail trimming INDICATIONS: The patient is a 6-year-old male, status post closed reduction percutaneous pinning of a left femoral shaft fracture about two weeks ago who presented with hardware protrusion from the lateral side of his distal left femur. The patient was evaluated and the risks and benefits of the operative procedure were extensively discussed with the patient’s mother. Consent for the procedure was obtained. The patient was evaluated by Anesthesiology Services and transferred to the operating room. PROCEDURE IN DETAIL: The patient was sedated and we proceeded with general anesthesia. The patient was draped and prepped in the usual manner. The left femur was evaluated and images obtained with the help of the C-arm. Under C-arm observation, there was noted to be shortening of the femoral shaft due to distal hardware displacement. The left lower extremity was manipulated in order to obtain proper length of the femur, which was impossible to achieve. The decision was made to trim the Nancy nails on the lateral side and on the medial side due to impending protrusion of the medial Nancy nail. Using a C-arm, the lateral nail was trimmed about 1/2 inch, or about 1 cm, back to the level of the bone. The opening was washed with Betadine solution and sterile dressing was applied. The medial side was also prepped and the hardware was protruding through the skin. The hardware was trimmed about the same length, about 1/2 inch or 1 cm on the medial side of the left femur, back to the level of the bone using C-arm fluoro guidance. The opening was washed with Betadine solution. Both skin openings were covered with Xeroform dressings and Tegaderm applied. 1.1. Was this procedure performed on a body part or on a device? 1.2. Which four root operations are possibilities for coding this procedure and why? 1.3. Which root operation is the appropriate selection? 1.4. What approach value is supported by the documentation “Using a C-arm, the lateral nail was trimmed about ½ inch, or about 1 cm, back to the level of the bone”? 1.5. What code(s) should be assigned?

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