Wiki Ortho OP note question

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shepardcpc

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newly working for an ortho surgeon, the following is an op note. I need help with a CPT

Lt Thumb I&D with Debridement included bone

The patient's lt thumb was incised at the tip and two separate incisions were made along it radial aspect allowing for complete irrigation and debridement at the level of the distal phalanx as well as of the metacarpophalangeal joint.
 
Pointers. In orthopedics the diagnosis is very important. Why is the provider doing this? That is missing. Is this the entire note? I don't see bone debridement in that note. If the incision started at the tip and went to the MCP joint, was the joint capsule at the MCP or I/P entered into as well? Is there a code or codes that you think may fit this procedure, if so, what are they?
 
1) Pre and postoperative diagnosis: Left thumb osteomyelitis

2) had queried doctor if known does the debridement include joint, bone or only skin/subcutaneous tissue?

3) query reply was debridement included bone

4) the rest of the op note was: Cultures were taken from all 3 incisions. the wound was then thoroughly irrigated and wound was packed with xeroform. The patient was placed in a sterile and compressive dressing.

5) CPT 11044 is my guess which fails medical necessity
 
Your going to need to send this back to the provider to update the note. There is nothing in that note to indicate that there was any bone debridement. That needs to be documented in the body of the note. Code 11044 is for debridement of open wounds, this is not an open wound. The provider had to make an incision to reach the osteomyelitis of the bone. The code selection is going to be in the m/s system, not the integumentary. For now you need to send the note back.
 
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