KBean2018
Guru
Hello, I am trying to figure out the total cm. Would I only code 11043? Thank you in advance for any help.
Procedure(s):
DEBRIDEMENT SACRAL WOUND Procedure Note
Pre-op Diagnosis: Infected decubitus ulcer, stage IV (HCC) [L89.94, L08.9]
Post-op Diagnosis: SAME
CPT Code: Procedures:
* DEBRIDEMENT SACRAL WOUND, SKIN AND MUSCLE AND SOFT TISSUE.
ICD-10 : Post-Op Diagnosis Codes:
* Infected decubitus ulcer, stage IV (HCC) [L89.94, L08.9]
Findings: The skin looks macerated directly in the midline, this is the upper sacrum and the lowermost extent is about 3 fingerbreadths from the anus. Cutting mode cautery excises this skin, there is bleeding at the edges to enter a stringy, purple fluid-filled area. That is debrided bilaterally to bleeding, some fascia of the gluteus muscles removed bilaterally, some muscle is removed. Once debrided to healthy tissue, there is soft filmy tissue overlying the palpable sacrum but not the level of the coccyx. This area of palpable bone is about 3 cm longitudinally 2 cm bilaterally but bone itself is not exposed and the palpable bone is firm. We then used 3 L of pulsevac, any bleeding points are controlled with cautery, and the bed is hemostatically packed firmly with about a foot of Betadine-soaked Kerlix and the remainder folded over as a dry dressing. I had infiltrated, bilaterally, a total of 30 mL 0.5% Marcaine without epinephrine for postoperative pain control. The longitudinal defect of skin opening 6 cm, bilaterally 4 cm, these 3 cm deep with minimal undermining below about 2 cm.
Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia and then rolled to the padded right lateral decubitus position. The bilateral gluteus and sacrum to the level of the anus prepped with Betadine and draped. Cutting mode cautery excises the central natal cleft into a cavity, using Bonnie forceps, and retractors, any filmy tissue is debrided to healthy bleeding throughout except overlying the bone. We will save that for another day if required at all. Once hemostasis is secured after pulsevac, packed. Dressings are applied, she is rolled supine, extubated and transported to PACU
Procedure(s):
DEBRIDEMENT SACRAL WOUND Procedure Note
Pre-op Diagnosis: Infected decubitus ulcer, stage IV (HCC) [L89.94, L08.9]
Post-op Diagnosis: SAME
CPT Code: Procedures:
* DEBRIDEMENT SACRAL WOUND, SKIN AND MUSCLE AND SOFT TISSUE.
ICD-10 : Post-Op Diagnosis Codes:
* Infected decubitus ulcer, stage IV (HCC) [L89.94, L08.9]
Findings: The skin looks macerated directly in the midline, this is the upper sacrum and the lowermost extent is about 3 fingerbreadths from the anus. Cutting mode cautery excises this skin, there is bleeding at the edges to enter a stringy, purple fluid-filled area. That is debrided bilaterally to bleeding, some fascia of the gluteus muscles removed bilaterally, some muscle is removed. Once debrided to healthy tissue, there is soft filmy tissue overlying the palpable sacrum but not the level of the coccyx. This area of palpable bone is about 3 cm longitudinally 2 cm bilaterally but bone itself is not exposed and the palpable bone is firm. We then used 3 L of pulsevac, any bleeding points are controlled with cautery, and the bed is hemostatically packed firmly with about a foot of Betadine-soaked Kerlix and the remainder folded over as a dry dressing. I had infiltrated, bilaterally, a total of 30 mL 0.5% Marcaine without epinephrine for postoperative pain control. The longitudinal defect of skin opening 6 cm, bilaterally 4 cm, these 3 cm deep with minimal undermining below about 2 cm.
Description of Procedure: In the supine position with appropriate monitoring she received general anesthesia and then rolled to the padded right lateral decubitus position. The bilateral gluteus and sacrum to the level of the anus prepped with Betadine and draped. Cutting mode cautery excises the central natal cleft into a cavity, using Bonnie forceps, and retractors, any filmy tissue is debrided to healthy bleeding throughout except overlying the bone. We will save that for another day if required at all. Once hemostasis is secured after pulsevac, packed. Dressings are applied, she is rolled supine, extubated and transported to PACU