Toe Amputations

MelBarclay

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Our surgeon doesn't perform many amputations so just wanting to make sure I'm headed in the right direction....

Section of the op note:
2nd and 3rd toes of the right foot were amputated. Dead tissue on the dorsum of the foot was removed as well. The distal metatarsal heads were removed without complication.

I'm thinking
28810 (T6)
28810 (59) (T7)
and then the debridement would be included because he doesn't give depth or any detail to that part of procedure. Any suggestions would greatly be appreciated!!

Melanie
 

Orthocoderpgu

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Your coding of the amputation is correct, but the surgeon really should document the osteotomy and its approximate location. In the documentation above its really assumed that it was performed otherwise the heads would not have come off.

Don't confuse debridement of an open wound (110XX section) with the debridement performed as part of a surgical procedure. Any debridement that is performed as part of a surgical procedure (in this case the amputation of toes) is included with the procedure and not reported seperately.
 

MelBarclay

Contributor
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Location
San Antonio, TX
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Your coding of the amputation is correct, but the surgeon really should document the osteotomy and its approximate location. In the documentation above its really assumed that it was performed otherwise the heads would not have come off.

Don't confuse debridement of an open wound (110XX section) with the debridement performed as part of a surgical procedure. Any debridement that is performed as part of a surgical procedure (in this case the amputation of toes) is included with the procedure and not reported seperately.

Thanks so much, we can always use any advice to improve his dictation as well!
 
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