# Second opinion for cpt 28126



## vmounce (Jan 15, 2010)

Myself and another coder both agree with 28122 and 11044, but she also says 28126.  I don't see that or maybe I'm not understanding the op report.   I want someone elses opinion before I say anything.  I appreciate any info...

Thanks,
Vickie

Here is the op note:

 PREOPERATIVE DIAGNOSES:   

1.      Fracture of the distal left second metatarsal with osteomyelitis            sequestrum. 
2.      Left medial foot diabetic ulcer.

POSTOPERATIVE DIAGNOSES:    

1.      Fracture of the distal left second metatarsal with osteomyelitis of sequestrum. 
2.      Left medial foot diabetic ulcer.

PROCEDURE:   

1.      Excision of sequestrum/distal fracture fragment of left second metatarsal bone.
2.      Debridement of subcutaneous tissue and bone ends (distal second metatarsal and proximal second phalanx).

SPECIMENS:   

Second metatarsal bone for culture. 
Debrided tissue fragments to pathology. 


BRIEF HISTORY/INDICATIONS:  This is a 53-year-old diabetic with known peripheral arterial disease.  He has undergone amputation of the left first metatarsal and toe.  He has a residual wound on the medial aspect of the foot.  In the deep (lateral) aspect of this wound, a bone fragment was visible.  An x-ray was obtained and this showed that the distal metatarsal appeared to have fractured from the metatarsal shaft.  It appeared that there was osteomyelitis involving the bone and the phalanx and sequestrum.  I recommended removing the bone fragments and debriding the infected tissues.  I discussed with the patient and his daughter the procedure, anatomy, anesthesia, indications, risks, benefits, and alternatives in detail.  He understood and accepted all the risks for the potential benefits and gave fully informed consent.

OPERATIVE PROCEDURE:   Preoperatively, the patient was identified and the procedure was verified.  Informed consent was confirmed.  The patient was taken to the operating room and placed on the table in the supine position.  He was sedated and an ankle block was accomplished.  The foot was prepped and draped in the usual fashion.  

Working through the previous medial wound, the bone fragment was dissected free and extracted with the back of the scalpel.  Necrotic and fibrotic debris was debrided away with scissors, scalpel, and rongeur.  The ends of the second metatarsal and the proximal second phalanx were debrided with the rongeur.  

The wound was copiously irrigated.  It was cauterized to render it hemostatic.  It was irrigated again and then packed with one-inch NuGauze.  

Sterile dressings were applied.  Counts report was correct.  The patient tolerated the procedure well.  

I asked the patient to return to the office tomorrow for a dressing change and wound reevaluation.


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