cclarson
Guru
Hello,
The doctor performed an amputation revision for a traumatic amputation that occurred in May w/ a nail deformity which was caused by the amputation. Would I code this as S68.621A? Would that also encompass the nail deformity or would I need another dx code for that Dx?
Here is the report:
POSTOPERATIVE DIAGNOSIS:
Painful left index finger amputation with nail deformity.
OPERATION PERFORMED:
Left index finger revision of amputation.
INDICATIONS FOR PROCEDURE:
The patient is an 82-year-old male with painful left index finger amputation. His nail has a significant deformity. He is taken to the operating room today for surgical revision. I have discussed the surgery with him, the risks. He understands and would like to proceed.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed in the supine position on the operating room table. IV sedation was administered. I next administered a digital block at the base of left index finger. The left upper extremity was prepped and draped in the usual sterile manner. A Tournicot was applied.
First I excised the tissue around the nail deformity. I lifted up flaps so that the entire nailbed including all the germinal matrix could be excised. This was done which included this nail deformity. I then took a rongeur and took off some of the distal phalanx and smoothed it down with a rasp. The wound was then washed out vigorously. Skin closed with 5-0 nylon sutures. The Tournicot was removed. Xeroform, 4x4s, and a soft dressing were applied.
The doctor performed an amputation revision for a traumatic amputation that occurred in May w/ a nail deformity which was caused by the amputation. Would I code this as S68.621A? Would that also encompass the nail deformity or would I need another dx code for that Dx?
Here is the report:
POSTOPERATIVE DIAGNOSIS:
Painful left index finger amputation with nail deformity.
OPERATION PERFORMED:
Left index finger revision of amputation.
INDICATIONS FOR PROCEDURE:
The patient is an 82-year-old male with painful left index finger amputation. His nail has a significant deformity. He is taken to the operating room today for surgical revision. I have discussed the surgery with him, the risks. He understands and would like to proceed.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed in the supine position on the operating room table. IV sedation was administered. I next administered a digital block at the base of left index finger. The left upper extremity was prepped and draped in the usual sterile manner. A Tournicot was applied.
First I excised the tissue around the nail deformity. I lifted up flaps so that the entire nailbed including all the germinal matrix could be excised. This was done which included this nail deformity. I then took a rongeur and took off some of the distal phalanx and smoothed it down with a rasp. The wound was then washed out vigorously. Skin closed with 5-0 nylon sutures. The Tournicot was removed. Xeroform, 4x4s, and a soft dressing were applied.
Last edited: