Hi,
Could I get some input on this operative report please? I know that debridement of diabetic foot ulcers are coded between 11042-11047 but this report doesn't actually specify whether debridement of muscle/fascia was done. It says the bone was palpated but that's not very specific. I don't really think I should assume that he debrided muscle and fascia from that term. Also there doesn't appeare to be a size in sq centimeters. Any suggestions?
PREOPERATIVE DIAGNOSES
1. Left foot diabetic foot ulcer.
2. Anorectal condyloma.
POSTOPERATIVE DIAGNOSES
1. Left foot diabetic foot ulcer.
2. Anorectal condyloma.
PROCEDURE PERFORMED
Debridement of a left foot diabetic foot ulcer.
SPECIMENS
None.
DRAINS
None.
ESTIMATED BLOOD LOSS
Less than 5 mL.
ANESTHESIA
General endotracheal.
PROCEDURE IN DETAIL
After consent was obtained, the patient was taken back to the operating
room, placed in a supine position and placed under general endotracheal
anesthesia. His left foot was then prepped and draped in usual sterile
fashion with Betadine. The previous incision was explored and there was some purulent material that could be milked up on the medial aspect of his foot. The hemostats were used to probe the wound, and there was a tracking further proximally along the lateral aspect of the foot. Scissors were then used to open up this cavity, and a combination of blunt dissection and
hemostats were used to explore the cavity. The wound was opened to a
total of 7 cm, and the bone was palpated and appeared to be firm and
intact. The wound was then rinsed with normal saline and Bovie electrocautery was used to achieve hemostasis. Some fibrinous exudate
was cleaned off using sharp dissection, and the wound was then packed
with Kerlix, and the foot was wrapped with Kerlix. At this point we directed our attention towards the anorectal condyloma. The drapes were taken down and the patient was put in the lithotomy position. At this point was found to have active diarrhea. The decision was made to not proceed with the excision of the condyloma as patient was having active bowel movements and would compromise of the view. The patient was then cleaned up and extubated and transferred to the recovery room in a stable condition.
We recommend that the next time the patient returns to the OR to have a
prep prior to excision of the anal condyloma.
Thanks!
Could I get some input on this operative report please? I know that debridement of diabetic foot ulcers are coded between 11042-11047 but this report doesn't actually specify whether debridement of muscle/fascia was done. It says the bone was palpated but that's not very specific. I don't really think I should assume that he debrided muscle and fascia from that term. Also there doesn't appeare to be a size in sq centimeters. Any suggestions?
PREOPERATIVE DIAGNOSES
1. Left foot diabetic foot ulcer.
2. Anorectal condyloma.
POSTOPERATIVE DIAGNOSES
1. Left foot diabetic foot ulcer.
2. Anorectal condyloma.
PROCEDURE PERFORMED
Debridement of a left foot diabetic foot ulcer.
SPECIMENS
None.
DRAINS
None.
ESTIMATED BLOOD LOSS
Less than 5 mL.
ANESTHESIA
General endotracheal.
PROCEDURE IN DETAIL
After consent was obtained, the patient was taken back to the operating
room, placed in a supine position and placed under general endotracheal
anesthesia. His left foot was then prepped and draped in usual sterile
fashion with Betadine. The previous incision was explored and there was some purulent material that could be milked up on the medial aspect of his foot. The hemostats were used to probe the wound, and there was a tracking further proximally along the lateral aspect of the foot. Scissors were then used to open up this cavity, and a combination of blunt dissection and
hemostats were used to explore the cavity. The wound was opened to a
total of 7 cm, and the bone was palpated and appeared to be firm and
intact. The wound was then rinsed with normal saline and Bovie electrocautery was used to achieve hemostasis. Some fibrinous exudate
was cleaned off using sharp dissection, and the wound was then packed
with Kerlix, and the foot was wrapped with Kerlix. At this point we directed our attention towards the anorectal condyloma. The drapes were taken down and the patient was put in the lithotomy position. At this point was found to have active diarrhea. The decision was made to not proceed with the excision of the condyloma as patient was having active bowel movements and would compromise of the view. The patient was then cleaned up and extubated and transferred to the recovery room in a stable condition.
We recommend that the next time the patient returns to the OR to have a
prep prior to excision of the anal condyloma.
Thanks!