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Thread: Diabetic Toe Ulcer

  1. #1
    Join Date
    Apr 2007

    Question Diabetic Toe Ulcer

    AAPC: Back to School
    My doc did I&D of the right great toe ulcer including bone resection of the first metarsophalangeal joint and repair and closure of the ulceration.

    Any suggestions on how to code this?

  2. #2
    Join Date
    Apr 2007
    Albany, New York


    Can you provide some specifics of the OP report?
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    Join Date
    Apr 2007


    So far that's all he has given me.

  4. #4
    Join Date
    Apr 2007


    klash, let us know when you can post the note..this is not really something that can be coded without additional info.


  5. #5
    Join Date
    Apr 2007


    1. Diabetic ulcer of the right great toe.
    2. Deep infection of the right great toe involving the first
    metatarsophalangeal joint.
    3. End-stage osteoarthritis of the right first metatarsophalangeal joint.
    4. Diabetes mellitus.

    1. Irrigation and debridement of the right great toe ulcer including bone
    resection of the first metatarsophalangeal joint.
    2. Repair and closure of the ulceration.

    This 53-year-old gentleman who developed an ulceration over the dorsum of the
    right great at the first metatarsophalangeal joint. He did develop infection
    and was being treated as an outpatient with intravenous antibiotics through a
    peripherally inserted central catheter (PICC) line as well as oral
    antibiotics. He subsequently developed some exposed bone and on x-ray was
    noted to have end-stage osteoarthritis with a fractured osteophyte exposed in
    the wound. Because of the obvious risks of progressive deep infection and
    loss of limb, it was felt that the patient would best be served through
    operative intervention in the form as described above. A complete discussion
    of all risks, benefits, alternatives was undertaken with the patient. He
    understood the risks and they wish to proceed with the operation, therefore an
    informed consent was obtained prior to surgery.

    The fractured osteophyte was easily identified in the wound. It was
    dorsomedial. It was removed. The joint was exposed beneath this bone. No
    frank pus was encountered. The actual appearance of the foot appeared much
    better than on initial consultation, reflecting improvement on the antibiotic
    regimen. This included decreased swelling and decreased erythema. The bone
    resection was continued all around the dorsum of the first metatarsophalangeal
    joint appropriately contouring the dorsum of the joint so as to remove any
    bony pressure on the area of ulceration. The joint itself was explored and
    noted to be severely arthritic with eburnated bone. Careful attention was
    taken to identify that there was no residual bone pressure on the skin and
    ulceration prior to closure, ensuring that the bone resection was
    Once informed consent was obtained from the patient, he was taken to the
    operating room and laid supine on the operating table. General anesthesia wasachieved and appropriate intravenous prophylactic antibiotics were continued.
    All bony prominences were padded well as a tourniquet was placed high on the
    right thigh and the right lower extremity was prepped and draped in the usual
    sterile fashion from the tips of the toes to above the knee. The right lower
    extremity was elevated then for approximately 5 to 7 minutes and the
    tourniquet was inflated to 300 mmHg. The area of ulceration was then
    debrided. The exposed bone was immediately removed with a rongeur and the
    joint was explored. The joint was debrided. Heterotopic hypertrophic bone
    was debrided all around the first metatarsal head and slightly around the
    proximal phalanx but the majority was around the first metatarsal head. This
    included the use of rongeurs and also reciprocating rasp.

    Once the bony resection was completed, some infected granulation tissue was

    also debrided. The area was then copiously irrigated with antibiotic
    irrigation and closure ensued. The Penrose drain was placed with a small stab
    incision over the tip of a hemostat. The drain was then tied off. Closure
    was then performed. The deep periosteal and fascial tissues were closed with
    absorbable suture creating a satisfactory seal of the joint. Then the skin
    itself was closed with nylon suture over the drain. Care was taken to avoid
    sewing in the drain. The wounds were then dressed with Betadine ointment,
    Adaptic, sterile gauze with gauze in the first web space. The tourniquet was
    then deflated as the bandage was further secured with sterile Sof-Rol and an
    Ace wrap around the ankle. The patient was recovered from general anesthesia,
    extubated and safely moved to the recovery room awake, alert and in stable
    condition. Of note: Needle and sponge counts were correct at the end of the
    case. Again there were no complications.

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