How would you code the following note? I don't feel like I could use a skin graft code since the donor site is the same location as the incision. Would I be able to use a complex closure since its definitely more involved than an intermediate repair?
The pt is returning today for mohs closure of the LEFT THIRD DIGIT
Because of the large size of the defect and the inability to completely close the wound side to side a small graft was planned to preserve this structure and function of the skin.
The wound was undermined with blunt dissection in the subcutaneous plane and a graft measuring 0.8cm x 0.5cm is sutured into place (donor site is right and left lateral aspects of the incision line). The deep dermis and deep subcutaneous fat were closed with 4-0 Vicryl suture. The epidermis was closed with 4-0 Dermalon suture. The skin surface was cleansed with hydrogen peroxide and a sterile dressing applied; wound care reviewed with the patient, and handout 6 given. The patient will return for suture removal in 12 days. The patient will follow up in 6 months.
capillary return on the left third digit after sutures are placed was less than 2 seconds
Length: 3.3cm
The pt is returning today for mohs closure of the LEFT THIRD DIGIT
Because of the large size of the defect and the inability to completely close the wound side to side a small graft was planned to preserve this structure and function of the skin.
The wound was undermined with blunt dissection in the subcutaneous plane and a graft measuring 0.8cm x 0.5cm is sutured into place (donor site is right and left lateral aspects of the incision line). The deep dermis and deep subcutaneous fat were closed with 4-0 Vicryl suture. The epidermis was closed with 4-0 Dermalon suture. The skin surface was cleansed with hydrogen peroxide and a sterile dressing applied; wound care reviewed with the patient, and handout 6 given. The patient will return for suture removal in 12 days. The patient will follow up in 6 months.
capillary return on the left third digit after sutures are placed was less than 2 seconds
Length: 3.3cm