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Need help w/operative report

  1. #1
    Post Need help w/operative report
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    PREOPERATIVE DIAGNOSIS: Gas gangrene of the left foot.

    POSTOPERATIVE DIAGNOSIS: Gas gangrene of the left foot.

    PROCEDURE PERFORMED: Amputation of the left fifth digit and the mid and distal
    half of the fifth metatarsal.

    ANESTHESIA: Spinal anesthesia.

    ESTIMATED BLOOD LOSS: Less than 3 ml.

    HEMOSTASIS: There was no hemostasis used.

    INDICATIONS FOR PROCEDURE:

    DESCRIPTION OF PROCEDURE: The patient was brought into the operating room, placed
    upon the surgical field in the supine position. The patient was anesthetized via
    spinal anesthesia with anesthesia extending from the waist down through the toes.
    The left foot was prepped and draped in the usual sterile manner. After verifying
    for anesthesia, we were ready to begin the surgical procedure. Attention was
    directed to the fifth ray of the left foot where by using a fresh #15 surgical
    blade, a 5 cm fish-mouth style incision was made at the level of the fifth
    metatarsal phalangeal joint of the left foot. Incision was deepened down through
    the same plane down to and through the joint capsule. Special attention was paid
    to all bleeders which were bovied, ligated and retracted out of the surgical field
    appropriately. The fifth digit was then resected in toto, passed off the surgical
    field and sent for pathological study. Deep aerobic and anaerobic cultures were
    obtained.

    Attention was then directed to the head of the fifth metatarsal. The head of the
    fifth metatarsal was discolored and necrotic. The distal half of the fifth
    metatarsal was also resected in toto and passed off the surgical field and sent for
    pathological study. The surgical site was then probed for all existing necrotic
    tissue. All existing necrotic tissue was then debrided in toto and passed out the
    surgical field and sent for pathological study. The area was then flushed and
    copious amount of normal sterile saline solution impregnated with 1 gram of Ancef
    antibiotic via the pulse lavage irrigation system. The surgical site was then
    dressed with topical thrombin impregnated Gelfoam.

    Would you code this as DX: 785.4 CPT 28810 T4?
    Yolanda T. Haskins CPC, CRC, OHCC, AAPC Fellow
    Past AAPCCA Board of Directors 2014 - 2017


    Alexandria, VA Chapter

    ~ Practice Kindness ~

  2. #2
    Location
    High Point, NC
    Posts
    84
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    I would code the procedure CPT 28810-52 (amputation, metatarsal, with toe, single; reduced service since the entire metatarsal was not removed). The provider stated Gas Gangrene, so DX 040.0 would be appropriate.
    Cindy Gallimore, CPC, CENTC

  3. #3
    Default
    Thanks for the response
    Yolanda T. Haskins CPC, CRC, OHCC, AAPC Fellow
    Past AAPCCA Board of Directors 2014 - 2017


    Alexandria, VA Chapter

    ~ Practice Kindness ~

  4. #4
    Default
    I am also battling with this one. What about coding 28820 for the amputation and then 28122 for partial excision of metatarsal?

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