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Hip infection 26992?

  1. #1
    Location
    Columbus, Ohio
    Posts
    106
    Red face Hip infection 26992?
    Medical Coding Books
    Hello helpful coders, the surgeon did an I&D for a hip infection and wants to use 26992 which is for infection of bone. I have read the op note several times and he did not document cutting to bone. Should the correct code be the 26990 or could I use the 27030 arthrotomy with hip drainage since he did put in a drain. Thanks again for your input. I just wanted to have someone to run this by. Paula

    INDICATIONS
    The patient is a 61-year-old who sustained a right hip fracture
    approximately 2 weeks ago, underwent hemiarthroplasty. She was
    discharged from here doing fine. She was at the nursing facility and
    had increased drainage and was brought to the hospital for evaluation.
    She was admitted and set up for surgery.
    PROCEDURE
    The patient was identified in preop holding both verbally and by her
    identification tag, transferred to the op suite, placed on the OR table
    in the supine position. Anesthesia addressed the patient, gave general
    anesthetic, secured an airway. The patient was placed in the lateral
    decubitus position on a bean bag. The right side was towards the
    ceiling. All bony prominences were well-padded. An axillary roll was
    placed. She was secured. Right lower extremity was prepped, draped in
    sterile fashion after the staples were removed. The patient's incision
    had erythema and some drainage. Dissection was carried down through the
    skin. The skin edges were ellipticized, and suture was removed, the
    Vicryl suture. She had a large hematoma and serous fluid. She had no
    gross pus. The tensor fascia lata was intact. The Vicryl sutures were
    removed from this, and there was hematoma in the joint. There was no
    frank pus. She underwent irrigation and debridement. The skin edges,
    subcutaneous tissue, fat, deep tissue was debrided. All the infectious
    tissue and tissue that appeared questionable was removed. Neurovascular
    structures were gently protected. The Ethibond and Vicryl sutures were
    removed that were placed from prior surgery. After thorough
    debridement, she was irrigated with pulse lavage with 12 liters of
    normal saline. The middle 2 had bacitracin. After thorough lavage, the
    tissue seemed appropriate. The hip was stable. The deep fascia was
    tissue and tissue that appeared questionable was removed. Neurovascular
    structures were gently protected. The Ethibond and Vicryl sutures were
    removed that were placed from prior surgery. After thorough
    debridement, she was irrigated with pulse lavage with 12 liters of
    normal saline. The middle 2 had bacitracin. After thorough lavage, the
    tissue seemed appropriate. The hip was stable. The deep fascia was
    closed with 0 PDS, 2-0 PDS closed subcu, and #2 nylon suture with a
    vertical mattress stitch closed the skin. Sterile dressing was placed.
    She had a drain placed deep into the hip prior to closure and was
    transferred to PACU. She will be admitted for IV antimicrobial
    treatment for cultures, and ID will be consulted. Will treat her with
    Arixtra 2.5 mg for DVT prophylaxis and discontinue the Lovenox treatment
    and continue SCDs. Will progress her with therapy and follow her wound
    and hip..

  2. #2
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    Paula,

    The 26990 would be more appropriate for this case

    Mary

  3. #3
    Location
    Columbus, Ohio
    Posts
    106
    Default
    Mary, thanks for confirming that code. Paula

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