ReignRuby
Contributor
I have assigned CPT 11042 to the op note below. I have not coded very many of these cases. Is this correct and covering everything the physician performed? Would this include the suture removal?
I code for an ASC.
POSTOPERATIVE DIAGNOSES: Left index finger pain status post
complex nailbed repair/open fracture of distal phalanx and
laceration of repair.
PROCEDURES PERFORMED: Debridement of left index finger, removal
of deep sutures, ablation of nailbed, debridement down to the
bone.
I then made a longitudinal dorsal incision over
the distal phalanx/nailbed. Once through the skin, I did
encounter a small area of remnant nailbed, which was likely
causing discomfort as there tried to grow nails underneath the
skin. I excised this nailbed in its entirety and then also
cauterized the border to fully ablate it. I also removed three
deep sutures that were non-dissolvable at the attachment of the
extensor mechanism at the base of the proximal phalanx. I also
removed a deep Monocryl suture from the distal radial tip. I
also debrided significant amount of scar tissue. Once this was
done, I irrigated the wound and closed the skin dorsally using
interrupted 4-0 Prolene suture.
POSTOPERATIVE DIAGNOSES: Left index finger pain status post
complex nailbed repair/open fracture of distal phalanx and
laceration of repair.
PROCEDURES PERFORMED: Debridement of left index finger, removal
of deep sutures, ablation of nailbed, debridement down to the
bone.
I then made a longitudinal dorsal incision over
the distal phalanx/nailbed. Once through the skin, I did
encounter a small area of remnant nailbed, which was likely
causing discomfort as there tried to grow nails underneath the
skin. I excised this nailbed in its entirety and then also
cauterized the border to fully ablate it. I also removed three
deep sutures that were non-dissolvable at the attachment of the
extensor mechanism at the base of the proximal phalanx. I also
removed a deep Monocryl suture from the distal radial tip. I
also debrided significant amount of scar tissue. Once this was
done, I irrigated the wound and closed the skin dorsally using
interrupted 4-0 Prolene suture.