Wound repair- RT & LT thigh
My physician did would repairs on the right and left thighs.
Left Thigh was a laceration 2.5 cm. MD made eliptical excision 4cm in length, irrigated and explored wound. Simple closure.
Right thight was 2.5 cm laceration. Just irrigation and closure w/ 2 mattress sutures.
My first question is what to code L. Thigh repair? 12001 for 2.5cm original laceration or the 12002 which would be the 4cm excision created.
my second question is if it is would I add both RT & LT thigh repairs together as you add together lengths of areas in the same classification, or since they are RT & LT if I could use two individual codes w/ 50- RT & LT mods?
PROCEDURE NOTE: After the induction of satisfactory general anesthesia,
the patient was prepared and draped in a sterile manner in the supine
position. Local anesthesia, consisting of 0.5 percent Marcaine with
epinephrine, was infiltrated into the skin of both operative sites. An
elliptical skin incision was made around the wound over the left ileum
for a total length of 4 cm. Hemostasis was achieved with
electrocautery. The wound cavity was palpated with an index finger, and
the bone fragments palpated. There were not on laying free in the
wound, and were left in place. There is no palpable foreign material.
The wound was lavaged with nearly 3 liters of saline using a Pulsavac
device. The wound was then flushed with 0.5 percent Marcaine with
epinephrine and the skin approximated using interrupted simple and
vertical mattress sutures of 3-0 nylon.
Attention was turned to the right thigh wound which, again, was
infiltrated with 0.5 percent Marcaine with epinephrine and the skin
debrided. The wound was palpated with findings as above. The wound was
lavaged, again, using the Pulsavac with 1 liter of saline. The skin was
reapproximated using 2 interrupted vertical mattress sutures of 3-0
nylon. Sterile light dressings were applied, and the patient awakened
and sent from the operating room in a stable condition.
Rachell Lindley, CPC
Multispecialty Clinic Coding