adiemeyer
New
Please help! I have a patient who had multiple procedures done the same day by two different providers and I'm struggling with the coding. I have reached out to another coding at my job for help but her coding was rather different than mine so now I'm even more confused. Any guidance ya'll can give me would be appreciated. I've read the procedure guidelines multiple times and I'm still not sure. Patient is under the age of 10 y/o.
1st note
Operative Note
1. Preparation of recipient site - right hand 1.5% TBSA
2. Preparation of recipient site - right lower arm 0.75% TBSA
3. Full thickness skin graft to right palm [4 x 3.5cm] and right palmar thumb [3x2cm]
4. Split thickness skin graft (sheet) to right lower arm [8cm x 5cm]
5. Split thickness skin graft (sheet) to right hand palmar aspect [7cm x 2.5cm] and digits 2,3,4,5
6. Burn wound debridement to left hand 1% TBSA palmar aspect
7. Placement of negative pressure wound therapy device to right forearm and hand.
8. Adjacement tissue rearrangement - right thigh (see Dr. S -plastics intraoperative consult)
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary per policy. The patient has been actively warmed in preoperative area. Preoperative antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis are not indicated.
The patient was brought to the OR and placed under GETA. The previous dressings were removed. The right palm was measured and found to be full thickness from wrist up to all palmar aspect of the digits. Thus we called Dr. Shah for an intraoperative consult for assistance with full thickness skin harvest with adjacent tissue rearrangement (please see her note for details).
The full thickness areas were tangentially excised using the weck blade at 6/1000 thickness down to healthy tissue. Hemostasis was achieved with bovie and thrombine.
The split thickness donor skin was obtained from the right and left lateral thigh using the dermatome at 10/1000 thickness. Donor site dressed with Xeroform.
The full thickness sheet graft and split thickness sheet graft were sutured on with 5-0 chromic in an interrupted fashion to the wrist and palm. The grafts were pie crusted. The graft was covered with bacitracin/adaptec and a negative pressure wound therapy device placed.
The left palm was dressed with bacitracin/xeroform/dermanet/kerlix/ACE after debribdement of all fibrinous exudate with moist lap sponge.
The patient tolerated the procedure.
Findings:
Full thickness burn right palm and digits 1,2,3,4,5 (1.5%)
Full thickness burn right forearm (0.75% TBSA)
Deep partial thickness burn left palm (1% TBSA)
My CPT coding - 15240-52-62, 15120 (I think I need to query the provider for the total TBSA for the STSG), 15004, 15005 x 2, 16020-59 (or XS)
**2nd note**
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary per policy. The patient has been actively warmed in preoperative area. Preoperative antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis are not indicated.
Findings: 10x5cm adjacent tissue rearrangement for closure of 5x6cm full thickness skin graft harvested from the right groin.
The patient was brought to the operative room and placed on the table in the supine position. GETA anesthesia was induced without complications. The patient was placed in the supine position and prepped and draped in the usual sterile fashion. A timeout was performed.
6cc of 1% lidocaine with epinephrine was infiltrated into the right groin in the areas of the FTSG harvest. I had measured out a 5x6cm rhomboid area and designed a rhomboid flap. After infiltration of the area, the FTSG area was incised with a knife and then removed using scissors. It was defatted on the back table and pie-crusted. The area of harvest was undermined along all edges. The most medial aspect could be approximated using 3-0 PDS and 3-0 vicryl sutures. The central area could not be closed so I designed a rhomboid flap extending laterally which was incised and the flap was rotated medially to close the defect. It was closed with 3-0 PDS, 3-0 vicryl, and the skin was approximated with 3-0 Prolenes in a matress fashion. The incision was covered with dermabond and steristrips and the dressed with 4x4 and tegaderm. The FTSG was brought to the hand (previously debrided - see Dr. L's operative note) and used to cover the right palm in the area of the 1st webspace and the right volar thumb which were the areas of the greatest burn depth and where we were most concerned about him developing contractures. The case was then turned back to the trauma team for placement of the STSG.
The patient was awakened from anesthesia without complications and was taken to the PACU in stable condition. The family was updated immediately after the procedure. All counts were correct.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Procedural Statement: I am a faculty provider and I personally performed the procedure.
*My CPT coding - 14301, 15240-52-62
Thanks,
Adrienne
1st note
Operative Note
1. Preparation of recipient site - right hand 1.5% TBSA
2. Preparation of recipient site - right lower arm 0.75% TBSA
3. Full thickness skin graft to right palm [4 x 3.5cm] and right palmar thumb [3x2cm]
4. Split thickness skin graft (sheet) to right lower arm [8cm x 5cm]
5. Split thickness skin graft (sheet) to right hand palmar aspect [7cm x 2.5cm] and digits 2,3,4,5
6. Burn wound debridement to left hand 1% TBSA palmar aspect
7. Placement of negative pressure wound therapy device to right forearm and hand.
8. Adjacement tissue rearrangement - right thigh (see Dr. S -plastics intraoperative consult)
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary per policy. The patient has been actively warmed in preoperative area. Preoperative antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis are not indicated.
The patient was brought to the OR and placed under GETA. The previous dressings were removed. The right palm was measured and found to be full thickness from wrist up to all palmar aspect of the digits. Thus we called Dr. Shah for an intraoperative consult for assistance with full thickness skin harvest with adjacent tissue rearrangement (please see her note for details).
The full thickness areas were tangentially excised using the weck blade at 6/1000 thickness down to healthy tissue. Hemostasis was achieved with bovie and thrombine.
The split thickness donor skin was obtained from the right and left lateral thigh using the dermatome at 10/1000 thickness. Donor site dressed with Xeroform.
The full thickness sheet graft and split thickness sheet graft were sutured on with 5-0 chromic in an interrupted fashion to the wrist and palm. The grafts were pie crusted. The graft was covered with bacitracin/adaptec and a negative pressure wound therapy device placed.
The left palm was dressed with bacitracin/xeroform/dermanet/kerlix/ACE after debribdement of all fibrinous exudate with moist lap sponge.
The patient tolerated the procedure.
Findings:
Full thickness burn right palm and digits 1,2,3,4,5 (1.5%)
Full thickness burn right forearm (0.75% TBSA)
Deep partial thickness burn left palm (1% TBSA)
My CPT coding - 15240-52-62, 15120 (I think I need to query the provider for the total TBSA for the STSG), 15004, 15005 x 2, 16020-59 (or XS)
**2nd note**
Procedure Details:
The patient was seen in the preoperative area. The risks, benefits, complications, treatment options, non-operative alternatives, expected recovery and outcomes were discussed with the patient. The possibilities of reaction to medication, pulmonary aspiration, injury to surrounding structures, bleeding, recurrent infection, the need for additional procedures, failure to diagnose a condition, and creating a complication requiring transfusion or operation were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The site of surgery was properly noted/marked if necessary per policy. The patient has been actively warmed in preoperative area. Preoperative antibiotics have been ordered and given within 1 hours of incision. Venous thrombosis prophylaxis are not indicated.
Findings: 10x5cm adjacent tissue rearrangement for closure of 5x6cm full thickness skin graft harvested from the right groin.
The patient was brought to the operative room and placed on the table in the supine position. GETA anesthesia was induced without complications. The patient was placed in the supine position and prepped and draped in the usual sterile fashion. A timeout was performed.
6cc of 1% lidocaine with epinephrine was infiltrated into the right groin in the areas of the FTSG harvest. I had measured out a 5x6cm rhomboid area and designed a rhomboid flap. After infiltration of the area, the FTSG area was incised with a knife and then removed using scissors. It was defatted on the back table and pie-crusted. The area of harvest was undermined along all edges. The most medial aspect could be approximated using 3-0 PDS and 3-0 vicryl sutures. The central area could not be closed so I designed a rhomboid flap extending laterally which was incised and the flap was rotated medially to close the defect. It was closed with 3-0 PDS, 3-0 vicryl, and the skin was approximated with 3-0 Prolenes in a matress fashion. The incision was covered with dermabond and steristrips and the dressed with 4x4 and tegaderm. The FTSG was brought to the hand (previously debrided - see Dr. L's operative note) and used to cover the right palm in the area of the 1st webspace and the right volar thumb which were the areas of the greatest burn depth and where we were most concerned about him developing contractures. The case was then turned back to the trauma team for placement of the STSG.
The patient was awakened from anesthesia without complications and was taken to the PACU in stable condition. The family was updated immediately after the procedure. All counts were correct.
Complications: None; patient tolerated the procedure well.
Disposition: PACU - hemodynamically stable.
Condition: stable
Procedural Statement: I am a faculty provider and I personally performed the procedure.
*My CPT coding - 14301, 15240-52-62
Thanks,
Adrienne