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Exploration, extremity?

  1. Default Exploration, extremity?
    Medical Coding Books
    Any thoughts on this one?? Thanks.

    This is the op report....

    Puncture wound, right upper extremity. Rule out fasciitis.

    Puncture wound, right upper extremity with no deep infection identified.

    Exploration, right upper extremity.

    The patient was taken to the operating room. After induction of adequate anesthesia, the patient was prepped with Betadine and draped sterilely.

    The longitudinal incision was made in the right upper extremity laterally with a #15 blade. The puncture wound extended down to the humerus. The bone was significantly exposed. No significant necrotic muscle or fascia was identified. The muscle was somewhat tightened. The fascia was incised in a longitudinal fashion along the triceps muscle. Hemostasis was achieved with electrocautery. The wound was packed open with 3-0 nylon vertical mattress sutures in the skin allowing a relatively loose closure. The patient tolerated the procedure. Estimated blood loss was perhaps 30 mL. The patient was taken to the recovery room in stable condition.

  2. #2
    most def check out 20103, I think thats the best code for this procedure.

  3. Default thanks!!!
    Do you know how long I looked for that yesterday?!?!?! LOL
    I must have passed right over that many times. Thank you so much!!!!


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