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HELP Please!! partial phalanx amputation

K

klbecker

Networker
Local Chapter Officer
Messages
65
Location
Saginaw, MI
Any opinions would GREATLY be appreciated. I've read this note so many times and can not come up with anything....

This is a 7 yo patient who got their foot stuck in an ATV

"The toes were irrigated with 2 L of normal saline. The 2nd toe, the distal phalanx was gone. The middle phalanx bone was protruding. It was rongeured back only a millimeter or 2. I curetted out the inside of the bone as there was some minor debirs in it. There was inferior skin remaining. I closed this secondarily using 4-0 chromic catgut. With regard to the 3rd toe, there was a portion of the nail bed, still intact. A very small medial portion of the nail remained. I trimmed the nail back. I irrigated the wound. I performed minimal sharp debridement with a kinfe to freshen the edges. I then closed it with 4-0 chromic catgut..."

At 1st I was looking at amputation codes. But the distal portion of the phalanx was already gone. I was thinking of using 28124 or possible just using the debridement codes, 11044.

Please help!!
 
Amputation Codes

:cool:

In your posting, you do not state that the doctor removed anything; therefore, you cannot bill out an amputation CPT code.

You can, however, use an amputation (traumatic) ICD-9 code. Just be certain that the toe was removed due to this ATV injury and not already removed or congenitally missing. If one of those two applies, use an "absense" code instead.

I know you're looking for more of an answer than that, but I hope that helps.
 
The patient was transferred from another hospital to my Dr. In the OP note it states that the distal phalanx was already gone. I believe it was amputation at the time of the injury. I didn't think I could use an amputation code since the distal phalanx was already "gone". That's why I was leaning more towards a debriement code since she did rongeured the bone back a millimeter and curetted the bone due to debris in it. Your suggesting using am amputation dx code along with the procedure code?
Thanks for your response!!
 
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