Debridement coding

generic808

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I'm getting a claim kicked back and can't figure out why. The patient had an open wound to the right index finger which required debridement (11044) to prevent infection. Dx codes S61300A and M1A00X1 got denied. Any clue as to how to code a Dx for this particular claim? Thanks in advance!

S61300A - Unspecified open wound of right index finger with damage to nail, initial
M1A00X1 - Idiopathic chronic gout, unspecified site with tophus
 
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S61.300A is an unspecified open wound and M1A.00X1 is an unspecified site, so there's really no linkage between the two codes. Can you provide additional information from the documentation?
 

generic808

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Physical Exam
General: Well appearing, well developed woman HEENT: EOMI Pulm: Breathing easily, no audible wheeze Heart: RRR Abdomen: Non-distended Skin: No rashes Psych: A&Ox3, normal age appropriate behavior Ext: Right hand is WWP with good cap refill, large tophi noted in the index and middle fingers, there is breakdown of the skin of the index finger with a projecting horn of tophasious material, no sign of infection Left hand is WWP with good cap refill, tophi noted within the fingers, no breakdown or sign of infection

Procedure Documentation
I&D
Preoperative diagnosis: right index finger wound secondary to gout he tophi
Postoperative diagnosis: same
Procedure: the agreement of skin and subcutaneous tissue as well as bone and tophi of the right index finger
Anesthesia: Local anesthetic
Specimens: none
Complications: none
Description of procedure: After performing a full PARQ and obtaining consent, a lidocaine without epinephrine digital clock was performed. The spicual was removed. A curette was used to remove as much tophi as possible. The underlying bone was curetted. Skin and subcutaneous tissue were sharply excised with a curved Iris scissors.
Hemostasis was obtained with pressure. One was dressed with gauze and a gauze roll.

Thank you.
 
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I'm a bit confused because the documentation doesn't read to me like an I&D was done. It seems like there is quite of bit of information missing from the procedure note. For example, there's no discussion of an incision being made at all. If this is what the provider has documented in full, I would be skeptical of billing it unless the provider gives more specific information. In the exam, there is mention of skin breakdown but no mention that an actual open wound was present. Due to the lack of information, personally I would not bill for this.

Can you query the provider and see if more specific information can be added onto the procedure note?
 

generic808

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Yes, I will try to get to the provider but he works out of this office and another out of state so he's bouncing back and forth. And sorry, I forgot to add:

Discussion Notes
I spoke with Miss XXXXX at length regarding the diagnosis. I informed her that she would require debridement. I informed her and her daughter that the risks included, but were not limited to bleeding, infection, need for repeat debridement, recurrence, the possibility of requiring an amputation. I informed them that her phalanges have been destroyed by the gout.She stated that she understood. She had an opportunity to ask questions and I believe that I answered them to her satisfaction. She asked me to proceed with surgery and her daughter signed the consent form preoperatively.
She tolerated the procedure well. She will follow up in one to two weeks for repeat evaluation. They will so three times daily and cover with gauze. They will monitor for signs of infection.
 
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You definitely need more information. For example, the size of the wound is missing from what you posted. As previously mentioned, there's no discussion of how the wound was accessed, eg, via incision. And where it says "One was dressed with gauze and a gauze roll." makes me think that was more than one wound that was repaired. And does "breakdown of the skin" mean this was an open wound? All in all, the narrative is a mess and probably shouldn't have been billed because of it.

I can't really toss out any DXs because there's just not enough to go on. I do know that you to get as specific as possible though. Once you get additional info, let me know.
 

generic808

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danskangel313,

Sorry I took so long to get back to this. I was caught up in a million other things that were a priority. Anyway, here's the rest of the dictation from the surgeon. Thanks in advance!

His left upper extremity was elevated. His radial and ulnar arteries were occluded for a minute and the tourniquet was inflated to 250 mmHg, started by sharply excising all necrotic soft tissues at the tip of the digit. This required that the distal phalanx was removed. After excising all of the necrotic tissue and irrigating the abscess, there was not enough soft tissue to cover the middle phalanx as left with the option of leaving the middle phalanx exposed and fractured. I made the decision that I would not be able to cover the middle phalanx regardless and that fracture repair would not be able to be performed in this gentleman and thus the two distal fragments were sharply excised. The bony spicule was removed with a rongeur, so the tip was smooth. I irrigated copiously with 3 liters of normal saline confirmed there was no pus in the proximal flexor tendon sheath and then left the wound open.
 
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danskangel313,

Sorry I took so long to get back to this. I was caught up in a million other things that were a priority. Anyway, here's the rest of the dictation from the surgeon. Thanks in advance!

His left upper extremity was elevated. His radial and ulnar arteries were occluded for a minute and the tourniquet was inflated to 250 mmHg, started by sharply excising all necrotic soft tissues at the tip of the digit. This required that the distal phalanx was removed. After excising all of the necrotic tissue and irrigating the abscess, there was not enough soft tissue to cover the middle phalanx as left with the option of leaving the middle phalanx exposed and fractured. I made the decision that I would not be able to cover the middle phalanx regardless and that fracture repair would not be able to be performed in this gentleman and thus the two distal fragments were sharply excised. The bony spicule was removed with a rongeur, so the tip was smooth. I irrigated copiously with 3 liters of normal saline confirmed there was no pus in the proximal flexor tendon sheath and then left the wound open.

Are you certain this is the op note for the patient? I only ask before this narrative discusses a male patient and the previous information discusses a female patient with seemingly different problems. :confused:
 

generic808

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Are you certain this is the op note for the patient? I only ask before this narrative discusses a male patient and the previous information discusses a female patient with seemingly different problems. :confused:

LOL you are right! Sorry, I'm drowning in things and I'm all over the place. Will come back to this when I get caught up. Sorry.
 
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