rrrobinson05
Contributor
I could sure use some help in coding this Op report, we don't do many of these kinds of repairs. The codes I attempted to use came up with CCI Edits. Any help is appreciated.
I was looking at codes 13121 & 13122 X 2. I'm not sure about the heel repair....13131....
OPERATIVE REPORT
Preoperative Diagnosis: Auto versus bike, complex soft tissue injury
Postoperative Diagnosis: Same, right upper extremity avulsion injury, right heal laceration not involving the Achilles tendon.
Procedure Performed: Irrigation, debridement and complex closure of right shoulder soft tissue injury and right heal soft tissue injury
EBL: Minimal
Drains: None
Complications: None
Specimen: None * No specimens in log *
Indications: This is a 13 year old boy who was involved in an auto versus bike accident late the night of 9/10 who presented with multiple abrasions and soft tissue injuries, right clavicle fracture and mild pulmonary contusions. The patient was then indicated for washout and closure. The risks and benefits of the procedure were discussed with the father who agreed to proceed.
Findings: Large complex, avulsion type injury to the right upper extremity measuring 18 x 10 cm. Closed in layers with nylon on the skin. Right heel laceration (4 cm in length) over the Achilles tendon did not involve the tendon itself. Washed out and closed with nylon sutures.
Procedural Details: The patient was identified in the ED. The patient was brought to the operative suite and placed in the supine position. General anesthesia was induced. Ancef was administered for antibiotic prophylaxis. His large amounts of wounds were cleaned under anesthesia. The right arm and right ankle was then prepped with Hibiclens and draped in usual sterile fashion. A time out was performed to verify correct patient, diagnosis, procedure, equipment and personnel. No concerns were raised.
Attention was turned to the complex wound of the right shoulder. The area was irrigated with a pulse-lavage system copiously with 3 liters. The wound appeared clean. The edges of the inverted T shape injury were debrided sharply at the locations were the skin edge did not appear viable. The flaps of the wounds were secured in layers using 3-0 vicryl suture. The skin edges had mild tension when re approximated and therefore were closed with 3-0 nylon sutures in a horizontal mattress fashion. 5-0 vicryl sutures were used to better approximate the epidermal edges near the junction of the flaps. The wound appeared well approximated, without undue tension and the skin edges were well perfused. The wound was then dressed with xeroform gauze, 4x4s, kerlix and a net stocking.
Attention was then turned to the heel laceration. The Achilles tendon was visible but not injured and seen moving normally with ankle ROM. The wound was copiously irrigated and the skin was closed with 3-0 nylons in a horizontal mattress manner. This wound was similarly dressed with xeroform gauze, 4x4s and kerlix.
All sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well, was extubated and was transported to _____ in stable .
I was looking at codes 13121 & 13122 X 2. I'm not sure about the heel repair....13131....
OPERATIVE REPORT
Preoperative Diagnosis: Auto versus bike, complex soft tissue injury
Postoperative Diagnosis: Same, right upper extremity avulsion injury, right heal laceration not involving the Achilles tendon.
Procedure Performed: Irrigation, debridement and complex closure of right shoulder soft tissue injury and right heal soft tissue injury
EBL: Minimal
Drains: None
Complications: None
Specimen: None * No specimens in log *
Indications: This is a 13 year old boy who was involved in an auto versus bike accident late the night of 9/10 who presented with multiple abrasions and soft tissue injuries, right clavicle fracture and mild pulmonary contusions. The patient was then indicated for washout and closure. The risks and benefits of the procedure were discussed with the father who agreed to proceed.
Findings: Large complex, avulsion type injury to the right upper extremity measuring 18 x 10 cm. Closed in layers with nylon on the skin. Right heel laceration (4 cm in length) over the Achilles tendon did not involve the tendon itself. Washed out and closed with nylon sutures.
Procedural Details: The patient was identified in the ED. The patient was brought to the operative suite and placed in the supine position. General anesthesia was induced. Ancef was administered for antibiotic prophylaxis. His large amounts of wounds were cleaned under anesthesia. The right arm and right ankle was then prepped with Hibiclens and draped in usual sterile fashion. A time out was performed to verify correct patient, diagnosis, procedure, equipment and personnel. No concerns were raised.
Attention was turned to the complex wound of the right shoulder. The area was irrigated with a pulse-lavage system copiously with 3 liters. The wound appeared clean. The edges of the inverted T shape injury were debrided sharply at the locations were the skin edge did not appear viable. The flaps of the wounds were secured in layers using 3-0 vicryl suture. The skin edges had mild tension when re approximated and therefore were closed with 3-0 nylon sutures in a horizontal mattress fashion. 5-0 vicryl sutures were used to better approximate the epidermal edges near the junction of the flaps. The wound appeared well approximated, without undue tension and the skin edges were well perfused. The wound was then dressed with xeroform gauze, 4x4s, kerlix and a net stocking.
Attention was then turned to the heel laceration. The Achilles tendon was visible but not injured and seen moving normally with ankle ROM. The wound was copiously irrigated and the skin was closed with 3-0 nylons in a horizontal mattress manner. This wound was similarly dressed with xeroform gauze, 4x4s and kerlix.
All sponge, instrument, and needle counts were correct at the end of the case. The patient tolerated the procedure well, was extubated and was transported to _____ in stable .