Help with leg muscle resection?


El Mirage, AZ
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how would you code this?
this was from the doc:
Through his lateral calf incision I did a very aggressive resection of almost all of his musculature, and irrigation washout.
I then closed the wound.

Through his medial calf incision, I did a gentle or muscular resection, irrigation and washout, and partial closure

Through his thigh incision I only did I irrigation and washout

here is the op report:

The patient was brought back into the operating room, all the appropriate staff identified the correct patient site and extremity of surgery.
The lateral Incision was approached first. With mechanical and electrocautery stimulation, no contraction was seen in the anterior compartment, the lateral compartment or the posterior gastrocnemius musculature which was assessed through the incision. I began to sequentially resect the necrotic anterior lateral compartments. I did this at several levels assessing for deeper contractility, however no motor function was seen at all in these 2 compartment. I completely resected these 2 compartments and did coagulate bleeders as needed. The posterior lateral musculature, the gastrocnemius complex was assessed as well which was necrotic and noncontractile through the lateral incision. I resected this until I got to healthy bleeding contractile muscle bed.

I then approached the medial incision, the tissue here was more healthy in appearance, with contractility maintained throughout. So I simply can't clearly debrided and irrigated out this incision.
The thigh incision also had excellent contractility and healthy in appearance. I irrigated this out, but incision was still too swollen to close. I left this open for VAC dressing.

The medial incision has able to close proximally two thirds of it. I would left the distal one third open for VAC dressing.

A drain was placed in the lateral incision.

any help on this would be appriciated!

Last edited:


Best answers
On the Lateral side of the Lower Leg, he did a Decompressive Fasciotomy with debridement of necrotic muscle and tissue of the Anterior, Lateral, and Posterior Compartments, even though the Posterior Compartment debridement was "limited" to the lateral side. This is 27894.
On the Medial side of the Lower Leg, he did a Decompressive Fasciotomy only as he did not have to debride any additional tissue, but he was unable to completely close the wound, so it would qualify as a Fasciotomy. Only the Posterior compartment can be accessed from the medial side. This would be 27601.
In the Thigh, he did a Decompressive Fasciotomy only, with no debridement, of only one compartment. Since he was unable to close the wound, this would qualify as a Fasciotomy. This would be 27496.

Hopefully this helps.

Respectfully submitted, Alan Pechacek, M.D.