From the health record of a patient undergoing foot surgery in the outpatient surgical unit: Indication…
From the health record of a patient undergoing foot surgery in the outpatient surgical unit:
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. The infection
is now clear and the patient presents for wedge resection of the toenail. She also
has pernicious anemia, Friedreich’s ataxia, and heart disease. Because of these
conditions, a digital block will be used for the procedure.
Procedure: Wedge resection of toenail
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. A standard
digit block is performed with 1 percent lidocaine using a 10-ml syringe and a 30-gauge
needle. Approximately 3 ml is instilled on each side of the toe.
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
ICD-10-CM and CPT Code(s):