Wiki RT below-knee amputation stump wound/ulcer skin procedure

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KoBee

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In need of some skin wound expertise help, trying to make sure the correct codes are being captured based on the documentation, coworker and I feel the closes to this would be CPT code 11042/15999, I would really appreciate your help :)


PREOPERATIVE DIAGNOSIS:
Right below-knee amputation stump ulcer.
POSTOPERATIVE DIAGNOSIS:
Right below-knee amputation stump ulcer.
PROCEDURE PERFORMED:
Right below-knee amputation stump wound revision.
ANESTHESIA:
General with Dr. English.
ESTIMATED BLOOD LOSS:
5 cc.
FINDINGS:
Benign-appearing ulcer at the BKA stump. It was excised, debrided, and closed
primarily.
DETAILS OF THE PROCEDURE:
The patient is a 68-year-old female with prior below-knee amputation, developed
a necrotic wound and ulcer. She was consented for surgery, brought to OR in
supine position, sedated, and intubated without complication. Time-out per
protocol. Preoperative antibiotics given. The right BKA stump was prepped and
draped in the usual sterile fashion. A sharp dissection was used to excise the
tissue around that area and debrided down to healthy bleeding normal tissue.
Then, I proceeded to excise the ulcer itself and down to subcu and muscle and
fat were well-perfused tissue. Then, the wound was widened to create an
ellipse and close primarily with 2-0 nylon in an interrupted fashion. The
patient tolerated the procedure well, and she was extubated and returned to
PACU with vital signs stable.
 
Hello michiboo,

I agree with coding only CPT 11042 as the documentation reads as if the ulcer was in the subcutaneous tissue and provider only looked at the muscle/fat in the area that was well perfused. Not sure about coding for closure since there are no measurements or layers documented. I would not code unlisted excision of a pressure ulcer CPT 15999.
 
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