Kevinph84
Guest
Hello Everyone,
I was wondering if I could get some thoughts and suggestions on a case. Here are excerpts from the documentation posted below:
INDICATION: The patient is an unfortunate 75-year-old lady who had a hip replacement and hip got infected. She has had several revisions and she keeps getting subcutaneous deep wound infections. In the early part of this year, she had a nonhealing infected ulcer that was to be debrided. She now has a new area that we have been trying to treat conservatively without any success.
OPERATIVE PROCEDURE: The patient was brought to the operating room, positioned in the lateral decubitus position with the right side up. The right hip was then prepped and sterilely draped. Time-out was observed. Preoperative antibiotics were given. A curvilinear incision was made and we carried the dissection all the way down to the skin, subcutaneous tissue, and all the way down to the fascia of the lateralis muscle. A vast portion of this muscle had sort of become atrophic. There was also a very thick old granulation tissue. We debrided all of this and then irrigated with bacitracin solution. Following that, we closed the deep subcutaneous fascial layer with a 2-0 Vicryl, the superficial with the same, and then the skin was stabled. Blood loss was approximately 20 ml. Fluid replacement was in the form of electrolyte solution. A bulky pressure dressing was applied. The patient was brought back to the recovery room in a relatively stable condition.
I was wondering for the procedure code, if this would be report with a complex repair code (i.e. CPT 13120). The debridement (CPT 11043) is considered inclusive to these codes per NCCI edits. I noticed the physcian did not dictate the size.
For the diagnosis code, would it be appropriate to report 998.59 (Other Post-Op Infection) and then 707.8 (Chronic Ulcer of Other Specified Site) or 707.19 (Ulcer, Other Specified Site of Lower Limb). Then followed by V43.64 (Hip-Joint-Replaced). The infection is not identified.
What does everyone think? Am I selecting the correct codes? I don't code Ulcer surgeries often, so when I come across them I like to get second opinions. Thank you in advance for your help.
I was wondering if I could get some thoughts and suggestions on a case. Here are excerpts from the documentation posted below:
INDICATION: The patient is an unfortunate 75-year-old lady who had a hip replacement and hip got infected. She has had several revisions and she keeps getting subcutaneous deep wound infections. In the early part of this year, she had a nonhealing infected ulcer that was to be debrided. She now has a new area that we have been trying to treat conservatively without any success.
OPERATIVE PROCEDURE: The patient was brought to the operating room, positioned in the lateral decubitus position with the right side up. The right hip was then prepped and sterilely draped. Time-out was observed. Preoperative antibiotics were given. A curvilinear incision was made and we carried the dissection all the way down to the skin, subcutaneous tissue, and all the way down to the fascia of the lateralis muscle. A vast portion of this muscle had sort of become atrophic. There was also a very thick old granulation tissue. We debrided all of this and then irrigated with bacitracin solution. Following that, we closed the deep subcutaneous fascial layer with a 2-0 Vicryl, the superficial with the same, and then the skin was stabled. Blood loss was approximately 20 ml. Fluid replacement was in the form of electrolyte solution. A bulky pressure dressing was applied. The patient was brought back to the recovery room in a relatively stable condition.
I was wondering for the procedure code, if this would be report with a complex repair code (i.e. CPT 13120). The debridement (CPT 11043) is considered inclusive to these codes per NCCI edits. I noticed the physcian did not dictate the size.
For the diagnosis code, would it be appropriate to report 998.59 (Other Post-Op Infection) and then 707.8 (Chronic Ulcer of Other Specified Site) or 707.19 (Ulcer, Other Specified Site of Lower Limb). Then followed by V43.64 (Hip-Joint-Replaced). The infection is not identified.
What does everyone think? Am I selecting the correct codes? I don't code Ulcer surgeries often, so when I come across them I like to get second opinions. Thank you in advance for your help.