Need help w/operative report
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
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
AAPCCA Board of Directors 2014 - 2017
Region 1 - NorthEast - ME, NH, VT, MA, RI, CT, NY
Alexandria, VA Chapter
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