I am not sure if I have coding this correctly. Would like for someone to review and give any direction if I am correct or if I have missed something. Thanks in advance for your help! Pt sustained these injuries from sliding falling off a ladder sliding down a palm tree. So far, I have 25028 & 26011.
POSTOPERATIVE DIAGNOSES: Left middle finger wound, left small finger
wound, left forearm wound, foreign bodies in the
left middle finger, left small finger and left
forearm
PROCEDURES PERFORMED: 1. Irrigation and debridement of left forearm.
2. Removal of foreign body left forearm.
3. Irrigation and debridement of left middle
fingertip.
4. Removal of foreign body left middle finger.
5. Irrigation and debridement of left small
finger.
6. Removal of foreign body left small finger
We began with
an oblique incision over the left middle fingertip pad. We carefully dissected down and encountered a pus.
This was decompressed. We explored the wound and identified a 1-inch piece of wood which was
removed from the fingertip. The wound was then washed out thoroughly with normal saline. The wound
was then closed with 5-0 plain gut. He had a complex wound at the base of his left small finger at the
distal palm. We carefully extended this proximally and explored the wound. He had some purulence in
this region as well which was washed out. We identified about 1 cm piece of wood as well which was
removed. This wound was thoroughly washed out with normal saline and closed with Prolene. He had a
complex laceration approximately 6 inches in length on the medial forearm. We extended this proximally
and distally in longitudinal fashion with significant amount of necrotic tissue in the subcutaneous layer
which was debrided. There was a small piece of wood in this area which was removed as well. The
flexor pronator fascia was intact. We removed some of the necrotic tissue with a rongeur. We then
thoroughly washed the wound out with normal saline and it was closed with Prolene suture. He was
placed in a soft padded dressing and tolerated the procedure well.
POSTOPERATIVE DIAGNOSES: Left middle finger wound, left small finger
wound, left forearm wound, foreign bodies in the
left middle finger, left small finger and left
forearm
PROCEDURES PERFORMED: 1. Irrigation and debridement of left forearm.
2. Removal of foreign body left forearm.
3. Irrigation and debridement of left middle
fingertip.
4. Removal of foreign body left middle finger.
5. Irrigation and debridement of left small
finger.
6. Removal of foreign body left small finger
We began with
an oblique incision over the left middle fingertip pad. We carefully dissected down and encountered a pus.
This was decompressed. We explored the wound and identified a 1-inch piece of wood which was
removed from the fingertip. The wound was then washed out thoroughly with normal saline. The wound
was then closed with 5-0 plain gut. He had a complex wound at the base of his left small finger at the
distal palm. We carefully extended this proximally and explored the wound. He had some purulence in
this region as well which was washed out. We identified about 1 cm piece of wood as well which was
removed. This wound was thoroughly washed out with normal saline and closed with Prolene. He had a
complex laceration approximately 6 inches in length on the medial forearm. We extended this proximally
and distally in longitudinal fashion with significant amount of necrotic tissue in the subcutaneous layer
which was debrided. There was a small piece of wood in this area which was removed as well. The
flexor pronator fascia was intact. We removed some of the necrotic tissue with a rongeur. We then
thoroughly washed the wound out with normal saline and it was closed with Prolene suture. He was
placed in a soft padded dressing and tolerated the procedure well.