suzannereed
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Impression: traumatic burn to the leg.
Plan: After verbal consent was obtained to proceed with debridement, ulcer #1 was cleansed with sterile saline. Lidocaine ointment 5% followed by 20% bensocaine spray was applied topically for anesthesia. Patient only reported minimal sensation along the proximal aspect of the wound, but did not report any significant pain with debridement. The necrotic tissue was very adherent and very difficult to pick up with pickups and curved scissors. Therefore, using pickups and 11 blade, I performed excisional debridement, which was medically necessary to remove necrotic tissue and examine the wound bed and promote wound healing. I also used a bone curette to debride along the margin of the wound. Bleeding was controlled with direct pressure. The patient tolerated the debridement well. There was no significant discomfort. Post debridement, there was a fair amount of firm adherent eschar remaining. This was significantly improved with sharp excisional debridement. Post debridement, the wound measured 9.2 X 3.5 x 0.2 cm. The patient tolerated the debridement well. Post debridement, the wound bed appeared to be improved. Santyl and a dry sterile dressing was applied...
I am wondering if I should code this as a 16020. Another coder suggests 16035. Would it even be possible to code both, since it reads like both were done?
Any help would be greatly appreciated. Thanks, fellow coders in advance.
Plan: After verbal consent was obtained to proceed with debridement, ulcer #1 was cleansed with sterile saline. Lidocaine ointment 5% followed by 20% bensocaine spray was applied topically for anesthesia. Patient only reported minimal sensation along the proximal aspect of the wound, but did not report any significant pain with debridement. The necrotic tissue was very adherent and very difficult to pick up with pickups and curved scissors. Therefore, using pickups and 11 blade, I performed excisional debridement, which was medically necessary to remove necrotic tissue and examine the wound bed and promote wound healing. I also used a bone curette to debride along the margin of the wound. Bleeding was controlled with direct pressure. The patient tolerated the debridement well. There was no significant discomfort. Post debridement, there was a fair amount of firm adherent eschar remaining. This was significantly improved with sharp excisional debridement. Post debridement, the wound measured 9.2 X 3.5 x 0.2 cm. The patient tolerated the debridement well. Post debridement, the wound bed appeared to be improved. Santyl and a dry sterile dressing was applied...
I am wondering if I should code this as a 16020. Another coder suggests 16035. Would it even be possible to code both, since it reads like both were done?
Any help would be greatly appreciated. Thanks, fellow coders in advance.