joettamorales
Guest
Hello, I need some help. Pt had surgery this month and still within the global period, provided applies a Ridge leg cast on the sx site And toenail debridement noted for the RT foot. Would a modifier be needed for the ridge leg cast? Or is that casting within the global? He document a new total contact cast was applies but does not mention why the pt needed a new cast.
Coding:
99024
11720 Q8,79- not the surgery site
29445- LT
Q4038- LT
HPI
Patient present for post-op week #1. He reports doing well.
ROS
None recorded.
Physical Exam
Dermatological: Incision site well coapted with no signs of infection.
Neurological: Protective sensation intact bilaterally.
Musculoskeletal: Strength and ROM testing deferred.
Vascular: Pedal pulses palpable bilaterally. No edema. No varicosities.
Assessment / Plan
Discussion Notes
Discussed the treatment plan with the patient. A new total contact cast was applied and he will continue with his home strengthening program. Nails 1-5 right foot were debrided with a nail nipper and dremel to reduce risk of accidental infection or gangrene
Coding:
99024
11720 Q8,79- not the surgery site
29445- LT
Q4038- LT
HPI
Patient present for post-op week #1. He reports doing well.
ROS
None recorded.
Physical Exam
Dermatological: Incision site well coapted with no signs of infection.
Neurological: Protective sensation intact bilaterally.
Musculoskeletal: Strength and ROM testing deferred.
Vascular: Pedal pulses palpable bilaterally. No edema. No varicosities.
Assessment / Plan
Discussion Notes
Discussed the treatment plan with the patient. A new total contact cast was applied and he will continue with his home strengthening program. Nails 1-5 right foot were debrided with a nail nipper and dremel to reduce risk of accidental infection or gangrene