Debridement of Fat Necrosis, left buttock (CPT codes)

jsalzer50

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I'm wondering if the buttock is considered part of the leg or part of the trunk in a debridement operative report?

Below is the full practice report I have in my college coding class with the codes I chose and how I got to them..

If the buttock is part of the trunk, would go with 13101, 13102, 13102

If the buttock is part of the leg, would go with 13121, 13122, 13122

Thanks in advance for your help!

- Jake

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1. OPERATIVE REPORT, DEBRIDEMENT

LOCATION: Outpatient, Hospital

PATIENT: Jim ---------------

SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Fat necrosis, wound of left buttock

POSTOPERATIVE DIAGNOSIS: Fat necrosis, wound of left buttock

SURGICAL PROCEDURE: Debridement of fat necrosis (this is degeneration of the skin), complex wound, with closer of complex 15-cm wound.

ANESTHESIA: General endotracheal

SURGICAL FINDINGS: There is an area of about 4 x 6 centimeters diameter fat necrosis in the depth of the wound. The wound itself was initially about 3 centimeters in diameter.

ESTIMATED BLOOD LOSS: Negligible.

DESCRIPTION OF PROCEDURE: The patient’s left buttock was prepped with Betadine scrub and solution and draped in a routine sterile fashion. The area was extended to reveal about a 4 x 6 cm area of fat necrosis, which was debrided and submitted for permanent sections. Bleeding was electrocoagulated, and the wound irrigated with a liter of Ringer’s lactate. A #10 Jackson-Pratt drain was placed in the depth of the wound and brought out through the wound, suturing it to the wound with 0 Monocryl, closing the wound with subcuticular 2-0 Monocryl and a few horizontal mattress sutures of 2-0 Monocryl. Dressings consisted of Xeroform, Kerlix fluffs, and Elastoplast. The patient tolerated the procedure well and left the operating room in good condition. Pathology Report Later Indicated: Necrotic fat tissue

SERVICE CODE(S): 13121, 13122, 13122

CPT Index > Repair > Wound > Complex > 13100—13160

13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm (with the hope that buttock is part of the leg….)
13122 each additional 5 cm or less
13122 each additional 5 cm or less

ICD-10-CM DX CODE(S): L98.8
ICD-10-CM Index > Degeneration > Skin > L98.8 (Other specified disorders of the skin and subcutaneous tissue)
 
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