Indication Procedure Patient Explained for Students (Easy Guide)

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Original Question

Indication for Procedure: The patient is a 60-year-old female who has a persistently Ingrowing great toenail on the left foot that has had two past infections. Procedure: Partial excision of toenail, permanent Procedure Description: The patient is placed in the supine position, with the knees flexed, and the left foot is flat on the table. The toe is prepped and cleansed, and local anesthetic administered. After waiting 10 minutes, a sterilized rubber band is placed around the base of the toe. The toe is resterilized and draped with the toe protruding. A nail elevator is slid under the cuticle to separate the nail plate from the overlying proximal nail fold. The lateral one fourth of the nail plate is identified as the site for the partial lateral nail removal. A bandage scissors is used to cut from the distal end of the nail straight back beneath the proximal nail fold. A straight, smooth, new lateral edge to the nail plate is created. The lateral piece of nail is grasped with a hemostat and removed in one piece, pulling straight out. Electrocautery ablation is used to destroy the nail matrix where the nail was removed. The matrix is treated twice. Antibiotic ointment is applied and a bulky gauze dressing is placed. The foot is placed in a surgical boot. Post-op instructions are given for daily cleansing with warm water, and strenuous exercise is to be avoided completely for at least one week. The patient tolerated the procedure well and understands the discharge instructions. The correct codes for reporting by the physician will be: ICD-10-CM code: CPT code and modifier: “Enter with a dash between the CPT code and modifier like: 99212-25

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