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  1. Default Like a challenge?
    Medical Coding Books
    Have a patient with multiple returns to the OR. Everytime I think I have it coded out, I change my mind. Hoping I can get someone elses opinion. I know this is rather lengthy, but I thought I'd give it a shot.
    Here are the op reports....

    February 21, 2011
    PROCEDURE/OPERATION
    Incision hematoma left calf with full thickness debridement of skin down to fascia, evacuation of large hematoma containing at least 800 mL of clotted blood, placement of wound-vac.
    ANESTHESIA
    Spinal.
    DESCRIPTION OF PROCEDURE
    The patient was taken to the operating room and after induction of adequate spinal anesthesia, the patient was prepped with Betadine and draped sterilely. The patient was in a slightly lateral position to allow access to the lateral aspect of the left calf. An eschar measuring approximately 4 centimeters which was circular was noted. This was completely opened accessing out the large hematoma cavity. An additional 4 to 5 centimeters of non-viable tissue was appreciated. This was trimmed without significant bleeding from the wound edges. The hematoma was then evacuated. The Pulsavac was utilized and pulse irrigation allowed good cleaning of the wound. A rough debridement was then performed with gauze. Once this was completed, the wound-vac was placed. Good seal was obtained. A medium vac was utilized. The patient tolerated the procedure and was return to the recovery room in stable condition. Estimated fresh blood loss was essentially nil.

    February 24, 2011
    PROCEDURE/OPERATION
    Wound debridement, left lower extremity wound-vac placement.
    ANESTHESIA
    Spinal.
    DESCRIPTION OF PROCEDURE
    The patient was taken to the operating room and after induction of adequate spinal anesthesia, the patient was prepped with Betadine and draped sterilely.
    The foam was removed from the wound. There was marked undermining appreciated. The deep tissue over the fascia and musculature are starting to get some good granulation tissue. Unfortunately, the overlying skin is extremely thin and actually has a layer of hematoma within it and is clearly non-viable. There was continued debridement of that area. Distal to it, I saw that there were some bleeding wound edges. The wound-vac was replaced. The medium sponge was utilized and actually most of the sponge was required as it is a fairly large wound measuring at least 7 x 5 inches. The patient tolerated the procedure well. Repeat debridement and wound-vac placement under anesthesia will be required.

    February 27, 2011
    PROCEDURE/OPERATION
    Full thickness debridement of skin down to fascia with Wound Vac placement.
    ANESTHESIA
    Spinal anesthesia.
    DESCRIPTION OF PROCEDURE
    The patient was taken to the operating room after induction of adequate spinal anesthesia, the patient was prepped with Betadine and draped sterilely.
    The necrotic wound edges were dressed relative to previous trips to the operating room. The debridement was actually fairly minimal. These were passed off. The wound was thoroughly irrigated with saline. Deep in the recesses underneath the undermined edges, some hematoma was appreciated, and this was further cleared. Once this was completed, the large Wound Vac dressing was applied. Good seal was obtained. The patient tolerated the procedure.

    March 2, 2011
    PROCEDURE/OPERATION
    Venous access device replacement under spinal anesthesia.
    ANESTHESIA
    Spinal.
    DESCRIPTION OF PROCEDURE
    The patient was taken to the O.R. after induction of adequate spinal anesthesia. The patient was treated first by removing the Wound Vac sponge. There was some undermining and once the sponge was able to be well removed, it was clear that we are getting granulation tissue under the undermining which should respond to the Wound Vac. The wound was then irrigated with antibiotic solution and then a new Vac was placed. This was trimmed to a much smaller size without significant undermining to allow adhesion of the skin flaps. This will be continued such that a skin graft will be possible in the not too distant future. Dressing was applied. The Wound Vac was started with good seal appreciated.

    03/07/2011
    PROCEDURE/OPERATION
    Split thickness skin graft with Wound VAC placement to wound left lower extremity measuring 15 x 6 cm.
    ANESTHESIA
    General by LMA.
    DESCRIPTION OF PROCEDURE
    The patient was taken to the operating room. After induction of adequate general anesthesia, the patient was prepped with Betadine and draped. The wound was granulating nicely. It measured 15 x 6 cm somewhat elliptical in shape. The plan was to utilize the 1 x 1-1/2 mesher. The length was measured on the lateral aspect of the upper thigh. The graft was taken utilizing approximately 0.013 inch thickness. The mesher was then utilized and the graft applied. This appeared to be nicely adherent. The Adaptic gauze was placed followed by the Wound VAC. The patient tolerated the procedure and was taken to recovery room in stable condition.

  2. #2
    Location
    Fayetteville, NC
    Posts
    300
    Default
    Were the later procedures pre-planned?
    Without knowing whether or not they were planned in advance it is impossible to decide which modifier is applicable.
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

  3. Default
    They were somewhat expected, but not exactly planned. The dr assumed they might have to go back to the OR, but were taking it on a day by day basis.

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