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new coder needs help

  1. #1
    Default new coder needs help
    Medical Coding Books
    Any help is appreciated. Looking at 13121 fand 13122.

    Determination of intermediate repair vs complex repair.

    Size of wound 5 x 18 cm.

    procedure: closed layer of left lower extremity wound.

    op note reads: the left lower extremity was prepped and draped in standard sterile surgical fashion. The granulation at the base of the soft tissue wound was vigorously debrided with gauze moistened in saline and a large amount of the granulated fatty tissue was excised with cautery to decrease the bulk within the wound between the skin edges. The skin edges were debrided of their epithelialized edges and widely undermined circumferentially. Direct closure of the wound manually seemed to create undue tension but the wound could be closed with slight rotation of the lower skin flap medially and the upper skin flap laterally which created dog ears at the medial and lateral wounds. The wounds were extended slightly on each side and these dog ears were excised. The wound was then closed with multiple deep dermal sutures of 2-0 Vicryl followed by external stures of 2-0 nylon. The external sutures were done as a vertical mattress sutures at the mid wound followed by simple interrupted sutures towards the medial and lateral wound edges. Prior to close some bleeding vessels within the excised soft tissue were cauterized and/or closed with figure-of-eight 3-0 silk sutures. The wound was cleaned, dried and dressed with bacitracin ointment, sterile gauze, a clean gauze and an Ace wrap.

  2. #2
    Milwaukee WI
    Default Complex repair
    Physician's documentation outlines both debridement and that the wound was "widely undermined." These two elements qualify this as a complex repair per CPT.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    thank you for your help.

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