Help Please!!!


Local Chapter Officer
Asheville, NC
Best answers
I need help with coding this surgery.

The diagnosis is cellulitis right heel.

The procedure is listed as I&D of Lower Extremity.

Description of Procedure: The 3 mm sinus of the medial aspect of the mid-foot was explored by blunt dissection and found to communicate subcutaneously with a plantar eschar over the mid-foot, mid plantar. The eschar was removed and immediate purulent drainage encountered. This was also found to tunnel approximately 1-1/2 cm laterally for approximately 1 cm width. The eschar was removed sharply from this ulceration as noted above permitting further debridement of this tract. The 3 mm ulcer of the medial portion of the foot was extended for an additional 4 mm posteriorly permitting debridement of this tract and thorough saline antibiotic irrigation. Penrose drains were left in each wound. A plantar medial ulcer with black eschar was debrided and purulent material encountered directly beneath same. This was noted to tunnel to a direct plantar ulcer also with black eschar. This 1-1/2 cm eschar was removed with purulent drainage immediately beneath. Necrotic material for this exudate was removed. Over the lateral aspect there were 2 eschars. Each measured approximately 1/2 cm in diameter. Purulence was encountered beneath each of these eschars however neither was noted to track significantly. Over the medial aspect of the heel a 1/2 cm longitudinal incision was made. An additional abscess was appreciated in the subcutaneous tissue with the same purulent material and fibrinous exudate. This was debrided and irrigated copiously. Penrose drains left in the site as well.