ksb0211
Guest
I'm hoping that someone has some insight as to how I should code this one. Another coder insists that the only thing to be coded is the toe amputation. I dont' want to leave anything out. Any thoughts?!?
Cellulitis necrotizing infection of the left foot.
OPERATION PERFORMED
Incision, drainage and sharp debridement of left foot with resection of the proximal phalanx of the first toe and debridement of metatarsal head of the first toe.
ANESTHESIA
Spinal.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room after induction of adequate anesthesia, the patient was prepped with DuraPrep and draped. The patient had an obvious fluctuant abscess over the plantar aspect of the foot. The web-space between the first toe site where there had been a previous amputation of the second toe. An incision was made in the space and some frothy bubbling material was appreciated. With the incision deepened, gray necrotic tissue was noted. The incision was continued through the web-space on to the dorsal aspect of the foot. Debridement was performed. All tracts were extended to allow for better debridement of viable tissue. The great toe would not allow any type of ultimate closure of this wound. The decision was to do some further debridement. Once this was completed, the wound was thoroughly irrigated with antibiotic solution and then packed with antibiotic soaked gauze. The patient tolerated the procedure. Estimated blood loss was 50 mL. The patient was taken recovery room in stable condition.
Cellulitis necrotizing infection of the left foot.
OPERATION PERFORMED
Incision, drainage and sharp debridement of left foot with resection of the proximal phalanx of the first toe and debridement of metatarsal head of the first toe.
ANESTHESIA
Spinal.
DESCRIPTION OF PROCEDURE
The patient was taken to the operating room after induction of adequate anesthesia, the patient was prepped with DuraPrep and draped. The patient had an obvious fluctuant abscess over the plantar aspect of the foot. The web-space between the first toe site where there had been a previous amputation of the second toe. An incision was made in the space and some frothy bubbling material was appreciated. With the incision deepened, gray necrotic tissue was noted. The incision was continued through the web-space on to the dorsal aspect of the foot. Debridement was performed. All tracts were extended to allow for better debridement of viable tissue. The great toe would not allow any type of ultimate closure of this wound. The decision was to do some further debridement. Once this was completed, the wound was thoroughly irrigated with antibiotic solution and then packed with antibiotic soaked gauze. The patient tolerated the procedure. Estimated blood loss was 50 mL. The patient was taken recovery room in stable condition.