Wiki Modifiers driving me insane

[weshelman]

I am having a problem with a skin graft wound closure surgery. The wounds were on both legs, measured 14 cm X 12.5 cm on right medial calf. Two on right lateral calf measure 2.5 X 2 cm and 2.5 X 1.8 cm. All are full-thickness wounds with granulation tissue clean and ready for grafting. These are the notes:

She is brought into the operating room where after she underwent general anesthesia, she was prepped and draped in the usual sterile fashion. The wounds were all debrided sharply. The largest wound was debrided using the Weck blade. This was down to good bleeding tissue removing the irregular shaped granulation tissue. The edges of the wound were then cleaned up with a 15 blade. Spray thrombin was used throughout because I was planning to use anticoagulant postoperatively for DVT prophylaxis since she has bilateral lower extremity grafting.

At this point, split thickness skin graft was taken using the dermatome set at initially 12/100 of an inch, but then reset to 15/100 of an inch. The donor site was injected with modified Klein solution putting 250 mL of saline, 2 amps of epinephrine and 40 mL of Xylocaine with epinephrine infiltrated into it. The skin graft was then meshed 1:1.5, but it was not expanded. There was a fairly large donor site in order to try to get as much dermis to protect her for future wound issues. At this point, after it was meshed 1:1.5, it was placed on the skin graft on the open wound and then sewn in with 4-0 chromic suture.

All of the skin grafts were sewn in with 4-0 chromic suture. They were then dressed with Xeroform gauze, bacitracin ointment and I used foam stapled overlying this from the VAC. The foam was split for better approximation that was stapled in place and rubber feeding tubes were then placed after they were fenestrated more to allow for irrigation to keep the foam over the skin grafts moist. These were then tacked in place. The whole wound was then dressed with Kerlix gauze after antibiotic ointment was applied to the sides of the foam at the skin grafts. The donor site was then covered with the sticky Op-Site the came with the foam for the VAC. The VAC was not used, just the foam for the VAC. She was then dressed with pressure dressing and Ace wraps and she then had 2 fiberglass splints placed on either lower extremities keeping her ankle in a flexed position, taking care to preserve that there was no pressure on the actual heel. She tolerated the procedure well and was sent to recovery in good condition.

Codes we came up with were:
15100 - S81.801S
15101 - S81.801S
15100-XS - S81.802S
15002-59 - S81.801S
15003-59 - S81.801S
15002-XS - S81.802S
29515-50 - S81.801S, S81.802S

This is driving me crazy.

 

[mitchellde]

Why are you using the 7th character S for the closing of a wound? When you use the S you need another code for the late effect. Also the CPT codes are not laterality specific, it is the 1st 100 sq cm total, you have just over 194 sq centimeters so only the 15100 and one 15002 is what is needed.

 

[weshelman]

Why are you using the 7th character S for the closing of a wound? When you use the S you need another code for the late effect. Also the CPT codes are not laterality specific, it is the 1st 100 sq cm total, you have just over 194 sq centimeters so only the 15100 and one 15002 is what is needed.

We had been treating her in the office for over a month local wound care. Had wounds on both ankles ended up grafting on both. Passed the ICD-10 profieciency maybe I need to take another course. Between it and the X modifiers (I also answer the phone, make appointments, schedule surgery, proofread notes and balance the money.) I need to retire maybe.

 

[mitchellde]

Just because you have been treating her for a month does not automatically indicate the use of the S. Sequela means the injury has healed and there is a residual issue such as a scar. The question is what was the the original injury. Big the injury was an open wound that has been treated ongoing then it is still an active wound with active treatment. If the injury was not an open wound then what was it? Why does it require grafting. You just need to look at the whole story. A does not mean first encounter. It is active treatment. The active treatment from an injury could take place over several encounters. Your scenario could still be active or it could be subsequent it will depend on the nature of the injury. Was this a burn or abrasion? If so then you are using incorrect injury codes. With more information I can better assist.

 

[weshelman]

Just because you have been treating her for a month does not automatically indicate the use of the S. Sequela means the injury has healed and there is a residual issue such as a scar. The question is what was the the original injury. Big the injury was an open wound that has been treated ongoing then it is still an active wound with active treatment. If the injury was not an open wound then what was it? Why does it require grafting. You just need to look at the whole story. A does not mean first encounter. It is active treatment. The active treatment from an injury could take place over several encounters. Your scenario could still be active or it could be subsequent it will depend on the nature of the injury. Was this a burn or abrasion? If so then you are using incorrect injury codes. With more information I can better assist.

Thanks for trying to help me. I think my initial problem was a seminar I went to on ICD-10 early on that emphasized the A was initial encounter, D was for subsequent encounter, and S was for follow up. Apparently that was bad information and it stuck in my head.

She is unable to bear weight with these wounds and has lupus, long history of prednisone use, and these are complex open wounds that got worse with treatment she received at a local hospital from dressings applied too tightly for cellulitis. She developed septic shock, did not respond to wound vac, after the hospital released her they referred her to us for wound treatment as we had seen her for other problems in years past and have had to do other split-thickness skin grafts for similar problems.

The initial consult note reads: The right lower leg medial wound is 13 x 13 cm and she has two lateral wounds that are 2 x 2. The wound on her left lower leg is near her lateral malleolus and it is 5 x 3 cm. They were not epithelializing with regular wound care.