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Coding of a complex repair to the toe

  1. #1
    Question Coding of a complex repair to the toe
    Medical Coding Books
    Can someone help me code this op report out. I want to make sure that I bill this out correctly.

    Patient presents late morning with an injury to the left tow while mowing the lawn. He snagged his left great toe with the blade of the lawn mower. It split his toe taking off the top one half of the distal toe back to half of his distal phalanx, and also took off the tissue of his nail bed and back just behind the cuticle area.

    The toe was anesthestized with 1% of Xylocin an rubber band tourniquet was applied. After adequate anesthesia the toe was scrubbed sterilely prepped and drapped. The underlying portion of the toes was intact and it was decided that could be used as a flap to close the injury. The residual fragments of bone that were removed from the remaining soft tissue was trimmed and cleaned up. Since this was a traumatic dirty injury, until we could see good viable tissue and then the flap of the undersurface of the toe was brought over the remaining portion of the distal phalanx up to the dorsal skin margin and closed with a running stitch.

    Any help would be greatly appreciated.

  2. #2
    Depending on the size of the repair, codes 12041 or 12042 would work for this procedure.

  3. #3
    Thanks, that is the one thing that he didn't document, I am waiting for the addendum on the size. I appreciate the help.

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