I could use some help with CPT codes for this procedure please!
NAME OF OPERATION: DEBRIDEMENT OF INFECTED SOFT TISSUE OF THE LEFT CALF.
POST OPERATIVE DIAGNOSIS: CELLULITIS OF THE LEFT CALF, WITH SEPTIC THROMBOPHLEBITIS.
PROCEDURE IN DETAIL: THE PATIENT WAS TAKEN TO THE OPERATING ROOM AND PLACED IN THE SUPINE POSITION. AFTER THE APPROPRIATE INTRAOPERATIVE MONITORING DEVICES WERE ESTABLISHED, GENERAL ANESTHESIA WAS EXCELLENTLY INTRODUCED. THE AREA OF THE LEFT CALF WAS PREPPED AND DRAPED IN THE USUAL STERILE MANNER. A SHARP INCISION WAS MADE OVER THE MOST INDURATED AREA OF THE SOFT TISSUE AND WE DID NOT ENCOUNTER ANY PUS BUT DID DISCOVER THROMBUS. ON FURTHER INCISION, THE THROMBUS APPEARED TO BE WITHIN THE GREATER SAPHENOUS VEIN OF THIS AREA. I ELECTED TO REMOVE AN ELLIPSE OF SKIN AND SOFT TISSUE HERE AND EVACUATED ALL OF THIS CLOT. WE DISSECTED DOWN TO HEALTHY TISSUE. HEMOSTASIS WAS OBTAINED WITH CAUTERY. THE WOUND WAS THEN PACKED WITH NORMAL SALINE KERLIX, WRAPPING IT WITH A KERLIX WRAP AND AN ACE BANDAGE.
I would really appreciate some help...
Thanks!
NAME OF OPERATION: DEBRIDEMENT OF INFECTED SOFT TISSUE OF THE LEFT CALF.
POST OPERATIVE DIAGNOSIS: CELLULITIS OF THE LEFT CALF, WITH SEPTIC THROMBOPHLEBITIS.
PROCEDURE IN DETAIL: THE PATIENT WAS TAKEN TO THE OPERATING ROOM AND PLACED IN THE SUPINE POSITION. AFTER THE APPROPRIATE INTRAOPERATIVE MONITORING DEVICES WERE ESTABLISHED, GENERAL ANESTHESIA WAS EXCELLENTLY INTRODUCED. THE AREA OF THE LEFT CALF WAS PREPPED AND DRAPED IN THE USUAL STERILE MANNER. A SHARP INCISION WAS MADE OVER THE MOST INDURATED AREA OF THE SOFT TISSUE AND WE DID NOT ENCOUNTER ANY PUS BUT DID DISCOVER THROMBUS. ON FURTHER INCISION, THE THROMBUS APPEARED TO BE WITHIN THE GREATER SAPHENOUS VEIN OF THIS AREA. I ELECTED TO REMOVE AN ELLIPSE OF SKIN AND SOFT TISSUE HERE AND EVACUATED ALL OF THIS CLOT. WE DISSECTED DOWN TO HEALTHY TISSUE. HEMOSTASIS WAS OBTAINED WITH CAUTERY. THE WOUND WAS THEN PACKED WITH NORMAL SALINE KERLIX, WRAPPING IT WITH A KERLIX WRAP AND AN ACE BANDAGE.
I would really appreciate some help...
Thanks!
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