hallux ulceratioin

[Vanessa863]

PREOPERATIVE DIAGNOSIS: Left hallux ulceration, deep to subcutaneous tissue and a left second digit skin blister.
POSTOPERATIVE DIAGNOSIS: Left hallux ulceration, deep to subcutaneous tissue and left second digit superficial abscess of the skin.
PROCEDURE: Debridement of the left hallux ulceration with application of Clarix and incision and drainage of left second digit blister/abscess.
OPERATIVE TECHNIQUE: The patient was placed in the supine position and prepped in the usual aseptic technique. Attention was directed first to the left second digit where a small blister was identified. Blisters dimensions noted as above with minute amount of scant amount of purulence inside the blister. Blister did not probe deep and was in the most superficial skin layer. The purulence was swabbed for wound culture and to be sent for aerobic and anaerobic microbes. After this, attention was directed to the left hallux where a significant amount of hypertrophic tissue was noted. In fact the hypertrophic tissue covers the entirety of the wound and a large portion of the plantar medial hallux. Upon debridement of the callus with a 15 blade there was notably some stippling in there which as a differential also concerned about a plantar wart possibly there as well. As such, the hyperkeratotic tissue was sent in a formalin cup to pathology. Underneath all these hypertrophic tissue was a small ulceration measuring approximately 1 x 0.8 x 0.2 cm deep to subcutaneous tissue. With hyperkeratotic tissue around the wound and on the medial aspect of the hallux debrided off the wound was prepped with 15 blade, debrided until healthy granular bleeding was noted and then an application of Clarix was applied to the left hallux ulceration site. The ulceration site was dressed with Adaptic and 4 x 4 gauze. The second digit Betadine wet-to-dry gauze and the entirety was dressed with a Kerlix wrap. Patient tolerated the procedure well and patient will follow up in the office in 1 week.

Having trouble with coding , not at all familar with podiatry coding . Im trying to start my search in debridements, and looking at the measurments , any help would be amazing . thank you desperate FL cpc-a

 

[podcoder70]

Vanessa, the reason you are having difficulty has more to do with the lack of necessary detail in the note to properly code. The diagnosis states the wound is deep to subq tissue, however, the debridement does not state to what depth the wound was debrided. In addition, there is no documentation regarding what procedure was performed on the blister. The only thing that can be coded with this documentation is a callus debridement, and yet, there are no supporting systemic conditions.
I advise the provider document the following information: 1. how was the blister treated, i&d 10140? was it a puncture aspiration 10160? 2. To code the ulcer treatment, a number of things must be documented, first, the type of tissue that was debrided and to what depth it was debrided. Was subq tissue debrided? It needs to state that the ulcer type and drainage.
Once you know to what depth it was debrided, you will be able to code 11042,3 or 4.

 

[Vanessa863]

Vanessa, the reason you are having difficulty has more to do with the lack of necessary detail in the note to properly code. The diagnosis states the wound is deep to subq tissue, however, the debridement does not state to what depth the wound was debrided. In addition, there is no documentation regarding what procedure was performed on the blister. The only thing that can be coded with this documentation is a callus debridement, and yet, there are no supporting systemic conditions.
I advise the provider document the following information: 1. how was the blister treated, i&d 10140? was it a puncture aspiration 10160? 2. To code the ulcer treatment, a number of things must be documented, first, the type of tissue that was debrided and to what depth it was debrided. Was subq tissue debrided? It needs to state that the ulcer type and drainage.
Once you know to what depth it was debrided, you will be able to code 11042,3 or

You have helped and guided me in the direction to start, huge thank you!