How to Answer Procedure Performed Primary Questions (Complete Guide)

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Original Question

PROCEDURE PERFORMED: Primary repair of left Achilles tendon HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old male who states that he was playing frisbee he felt a sudden pop in the posterior aspect of his left leg. The patient was placed in posterior splint in the ED and was admitted today for surgery.PROCEDURE DESCRIPTION: After all potential complications, risks, as well as anticipated benefits of the proce¬dure were discussed with the patient, informed consent was obtained. The patient was then transferred to the operative table and placed in the prone position. All bony prominences were well padded at this time.Under general anesthesia, the left lower extremity was prepped and draped in the usual sterile fashion. The extremity was elevated and exsanguinated using an Esmarch and the tourniquet was inflated to 325 mmHg and kept up for a total of 40 minutes. After all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the Achilles tendon from its insertion proximal. Careful dissection was then taken down to the level of the peritenon. Once this was reached, full thickness flaps were performed medially and laterally. Next, retractor was placed. All neuro-vascular structures were protected. A longitudinal incision was then made in the peritenon and opened up exposing the tendon. There was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point. The plantar tendon was noted to be intact. The tendon was debrided at this time of hematoma as well as frayed tendon. Wound was copiously irrigated and dried. It appeared that there was sufficient tendon left in order to do a primary repair. Next #0 PDS on a taper needle was selected and a double Krackow suture (locking-loop) weave technique was used for the repair. The tendon ends came together very well and with a tight connection. Next, a #2-0 Vicryl suture was then used to close the peritenon over the Achilles tendon. The wound was once again copiously irrigated and dried. A #2-0 Vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the sub¬cuticular closure on the skin. Steri-Strips were then placed over the wound and the sterile dressing was applied and a short length fiberglass cast in a plantar position. What is the PCS code?

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