Orthopedic Coding Alert

An amputation surgery means that bone is being cut through and removed from the body of the patient. A surgical amputation could be the result of an accident or an earlier, deliberate surgical procedure that became infected or is severe enough to warrant removal of a limb or digit. When coding for amputation of fingers and toes in particular, coders should remember that tissue loss only does not constitute an amputation.

The Injury

Billie Jo McCrary, CPC, CCS-P, CMPC, practice manager of Wellington Orthopaedic and Sports Medicine in Cincinnati, a six-office practice with 18 physicians, shares an operative report of a two-stage toe amputation that presents some coding challenges. The surgery was performed on a 42-year-old male who had nearly amputated two of his toes in a lawn mower accident.

Indications for Operation

The patient) sustained near amputation of the right second toe through the base of the distal phalanx and a near amputation of the right great toe through the base of the distal phalanx. X-rays revealed comminuted fractures of the affected toes and clinical exam revealed significant soft tissue defects with a thin bridge of skin attaching the residual portion of the second toe and an oblique laceration through the germinal matrix of the great toe. X-rays also revealed that the distal half of the great toe distal phalanx was missing. There was a ragged dorsal flap of the great toe dorsally, which was attached by a bridge of skin medially.

In the Operating Room

Second toe: A bone resection through the interphalangeal joint of the second toe was carried out sharply with a knife. All skin edges were then resected along a 2-mm margin to remove all contaminated tissue. The subcutaneous layer was debrided as well sharply with a knife and a rongeur under loupe magnification.

Great toe: The distal portion of the distal phalanx was debrided with a rongeur and all bone edges were smoothed. The interphalangeal joint was stable and therefore the remainder of this bone was saved after it was debrided back to a clean margin. The subcutaneous layer was further sharply debrided under loupe magnification, removing all contaminated tissues. All skin edges were resected back to a 1- to 2-mm margin. The subcutaneous layer was then debrided. The skin edges were trimmed to provide for later flap closure.

The wounds on both toes were left open, with a plan to bring the patient back to the operating room (OR) within 36 to 48 hours for repeat irrigation, additional debridement and delayed primary closure. Upon return to the OR, additional debulking of subcutaneous tissue of the great toe was done, as was additional debridement of the subcutaneous tissue of the second [...]