AT2728
Expert
I'm a bit stuck on this, had the note stated a foreign body was removed I would have coded 10120. However, he states foreign body "reaction" to tick bite---per Integument in physical exam-rash is noted. I attached the procedure note and Skin notation on physical exam. I would really appreciate someone else's opinion--physician calls this debridment.
INTEGUMENT: Good turgor and normal healthy scheen a rash is noted on the left leg; the color is mainly Brawny; it is best characterized as confluent, macular, and 5 x5 cm quadrangular patch of reaction around a central 7 mm scab L lower leg medially;
Insect bite on leg
Patient has agreed to undergo wound care today. This has previously been diagnosed as a foreign body reaction, scabby crust and embedded tick remnants. Verbal consent was obtained from the patient. DEBRIDEMENT was performed in the following manner: using sharp instruments (scalpel with #15 blade) and forceps, the nonfunctional necrotic scab and foreign body reaction were removed.; The wound(s) is/are located at the: over the left, distal medial leg. Sterile technique was observed. The wound was cleaned with alcohol, antimicrobial soap and water, and betadine prior to the procedure. Patient did not have any complications with the procedure. Estimated blood loss was several drops cc. The post-procedure wound measurements are 0.5 cm in length, 0.5 cm in width, 0.2 cm in depth, and tunnelling was not present. The wound was dressed with antibiotic ointment, kling, and telfa pad. Post procedure instructions have been given to the patient.
INTEGUMENT: Good turgor and normal healthy scheen a rash is noted on the left leg; the color is mainly Brawny; it is best characterized as confluent, macular, and 5 x5 cm quadrangular patch of reaction around a central 7 mm scab L lower leg medially;
Insect bite on leg
Patient has agreed to undergo wound care today. This has previously been diagnosed as a foreign body reaction, scabby crust and embedded tick remnants. Verbal consent was obtained from the patient. DEBRIDEMENT was performed in the following manner: using sharp instruments (scalpel with #15 blade) and forceps, the nonfunctional necrotic scab and foreign body reaction were removed.; The wound(s) is/are located at the: over the left, distal medial leg. Sterile technique was observed. The wound was cleaned with alcohol, antimicrobial soap and water, and betadine prior to the procedure. Patient did not have any complications with the procedure. Estimated blood loss was several drops cc. The post-procedure wound measurements are 0.5 cm in length, 0.5 cm in width, 0.2 cm in depth, and tunnelling was not present. The wound was dressed with antibiotic ointment, kling, and telfa pad. Post procedure instructions have been given to the patient.
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