The health record of a patient admitted for a right total hip.
Need ICD-10-CM and CPT codes
CPT Procedure Cod 454. The following documentation is from the health record of a patient admitted for a right total hip. Preoperative Diagnosis: Right hip osteonecrosis, Ficat stage IV Postoperative Diagnosis: Right hip osteonecrosis, Ficat stage IV Procedure Performed: Right total hip arthroplasty Blood Loss: 350 cc Complications: None Implants Used: 1. DePuy Articul/EZE femoral head 28 mm 1.5, lot #1169939 2. DePuy large AML femoral component, 150 mm long, 45-mm offset, lot #YDZCV1000 3. DePuy hole eliminator, lot #YH9DH1000 4. DePuy pinnacle acetabular liner 28 mm, lot #X69AR1000 5. DePuy cancellous bone screw 25 mm long, lot #X2BEN1000 6. DePuy acetabular cup 36 mm, lot #X60CK1000 Indications for Operation: The patient is a 54-year-old male who is presented with long-standing right hip pain secondary to osteonecrosis. Nonsurgical treatment was unsuccessful. After risks, benefits, and alternatives of the surgery were explained to the patient, informed consent was obtained for this procedure. Details of Procedure: Patient was taken back to the operating room and placed on the operating table in a supine position. After induction of general anesthesia, the patient was placed in the left lateral decubitus position and the left lower extremity was prepped and draped in usual sterile manner. Lateral incision was made over the greater trochanter. This incision was approximately 15 cm long. It was carried down through subcutaneous tissue to the iliotibial band, which was incised longitudinally.
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