I am coding a wound care right now. Per report:
PLAN OF CARE: The left heel was debrided in an excisional fashion to
increase wound healing, decrease infection, decrease bioburden,
through and including the level of muscle with a sharp curette to 80%
of the dictated wound bed. The nurse assessment forms have
predebridement measurements. Minimal bleeding was controlled with
pressure. 5% topical lidocaine was applied prior to debridement.
The right dorsal foot wound was debrided in an excisional fashion to
increase healing, inhibit infection, and decrease bioburden including
the level of subcutaneous tissue with a curette. This was completed
to 100% of the wound bed. The nurse assessment forms have
predebridement measurements. Minimal bleeding was controlled with
pressure. 5% topical lidocaine was applied prior to debridement.
The other areas
were debrided in a selective fashion through and including the skin
to remove slough, biofilm, and nonviable material, completed with a
curette to 80% of the wound bed. The nurse assessment forms have
predebridement measurements. Minimal bleeding was controlled with
pressure and 5% topical lidocaine was applied prior to debridement.
She tolerated all the procedures well. There were no biopsies or
cultures taken. No sensitivities to review. Following debridement
and hemostasis, Silvadene was applied to all open areas of the right
lower extremity. The right foot and the left lateral leg covered
with a light dry sterile dressing. The right leg was then covered
over the scabbed areas to protect them. Iodoflex was then applied to
the left heel protecting the epithelialized bridge and then the VAC
was applied, that will be changed Monday, Wednesday, and Friday, set
to 125 mmHg.
The coder originally used:
11042-59
11043
95797
I would delete the 11042-59 and use modifier 59 on 97597, would I use the XS modifier as the other leg was done?
Please help, thanks!
Mary
PLAN OF CARE: The left heel was debrided in an excisional fashion to
increase wound healing, decrease infection, decrease bioburden,
through and including the level of muscle with a sharp curette to 80%
of the dictated wound bed. The nurse assessment forms have
predebridement measurements. Minimal bleeding was controlled with
pressure. 5% topical lidocaine was applied prior to debridement.
The right dorsal foot wound was debrided in an excisional fashion to
increase healing, inhibit infection, and decrease bioburden including
the level of subcutaneous tissue with a curette. This was completed
to 100% of the wound bed. The nurse assessment forms have
predebridement measurements. Minimal bleeding was controlled with
pressure. 5% topical lidocaine was applied prior to debridement.
The other areas
were debrided in a selective fashion through and including the skin
to remove slough, biofilm, and nonviable material, completed with a
curette to 80% of the wound bed. The nurse assessment forms have
predebridement measurements. Minimal bleeding was controlled with
pressure and 5% topical lidocaine was applied prior to debridement.
She tolerated all the procedures well. There were no biopsies or
cultures taken. No sensitivities to review. Following debridement
and hemostasis, Silvadene was applied to all open areas of the right
lower extremity. The right foot and the left lateral leg covered
with a light dry sterile dressing. The right leg was then covered
over the scabbed areas to protect them. Iodoflex was then applied to
the left heel protecting the epithelialized bridge and then the VAC
was applied, that will be changed Monday, Wednesday, and Friday, set
to 125 mmHg.
The coder originally used:
11042-59
11043
95797
I would delete the 11042-59 and use modifier 59 on 97597, would I use the XS modifier as the other leg was done?
Please help, thanks!
Mary