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Need help with op note.

  1. Default Need help with op note.
    Medical Coding Books
    "..Patient was placed on the table in the supine position. Right arm was abducted 90 degrees and her arm, flank and right breast were prepped and draped in the usual sterile fashion. The patient had a nonhealing radiation ulcer from a previous lumpectomy. She had a very large overhanging skin fold, which was not allowing the ulcer to heal, so this area was infiltrated with tumescent solution and the 3 and 4 mm cannula was used to aspirate this area to debulk it. 250 cc of tumescent solution was infiltrated. A total of 400 cc was removed, of which 300 cc was fat supernatant. Next, an elliptical incision was used to cut out the ulcer and this was previously marked in the sitting position. This was excised down to subcutaneous tissue. The entire length of the wound was 14 cm. The specimen was sent to pathology. After obtaining hemostasis with electrocautery the wound was closed in layers with 3-0 Vicryl and a running 4-0 Monocryl suture. A few interrupted 5-0 Monocryl were also placed. She was sent to the recovery room after placing a dressing in stable condition."

    I'd appreciate any thoughts on this. I was thinking 15877, 11406 and 12035 with dx of 707.9 The doc (I'm thinking because the payer would deny the lipo) coded complex closure and nothing else (13101,13102,13102).

    Thanks in advance.

  2. Smile

    Coding with complex closure will be more appropriate for this senario.

    Joseph Amalraj Antonisamy CPC-H

  3. Default
    Thanks for your help - can you explain why would you code complex closure and - would you code the lipo separately ? Thanks.

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