maxwell@marshall.edu
Contributor
My surgeons do a lot of truama and burns. I get so much conflicting information I decided to see how fellow coders were coding excisional debridement of burns. Some say use only the 16000 codes others say use the 15002 - 15005 codes. Any help would be greatly appreciated.
Sample OP Note:
Diagnosis: Third degree burns of shoulders, back, glanks and bilateral upper extremities
Procedure: excisional debridement of 2000 sq cm to above listed areas.
Description of Procedure:
Patient was taken to OR and placed under general anesthesia via ET tube previously placed. Pt placed in prone position and appropriately reinforced. the back, flanks, neck, shoulders and bilateral upper extremities were prepped and draped with Betadine. The betadine was washed off using warm sterile saline. Esmarch knives were used to excisionally debride all areas. the back had to be debrided down in the subcutaneous adipose tissue. the arms had to be debrided in a similar fashion due to the depth of the burn. this was taken down to healthy bleeding adipose, dermis and dermal tissues which was hemostased with saline and epinephrine soaked lap sponges and Bovie cautery. Upone adequate excisional debridement of about 2000 sq cm of these areas, silver nitrate dempened lap sponges were placed on the back and bilateral upper extremities. the arms were wrapped in Kerlix and a burn vest was applied to the back, shoulders and nec. Sponge, needle and instrument counts were correct at the end of the case.
Again, any help would be greatly appreciated.
Sample OP Note:
Diagnosis: Third degree burns of shoulders, back, glanks and bilateral upper extremities
Procedure: excisional debridement of 2000 sq cm to above listed areas.
Description of Procedure:
Patient was taken to OR and placed under general anesthesia via ET tube previously placed. Pt placed in prone position and appropriately reinforced. the back, flanks, neck, shoulders and bilateral upper extremities were prepped and draped with Betadine. The betadine was washed off using warm sterile saline. Esmarch knives were used to excisionally debride all areas. the back had to be debrided down in the subcutaneous adipose tissue. the arms had to be debrided in a similar fashion due to the depth of the burn. this was taken down to healthy bleeding adipose, dermis and dermal tissues which was hemostased with saline and epinephrine soaked lap sponges and Bovie cautery. Upone adequate excisional debridement of about 2000 sq cm of these areas, silver nitrate dempened lap sponges were placed on the back and bilateral upper extremities. the arms were wrapped in Kerlix and a burn vest was applied to the back, shoulders and nec. Sponge, needle and instrument counts were correct at the end of the case.
Again, any help would be greatly appreciated.