kpichon
Networker
I am needing help on the following note. The provider is wanting to bill 11042 with S91.302D Unspecified open wound left foot. Dx isnt payable per LCD policy. Her initial visit was billed as 10140 I&D of Hematoma with L08.9 and M10.09. I am really unsure if the cpt for this is correct and if so what the dx should be. Any help would be greatly appreciated.
HPI
Rose presents to the office today for a followup on her left great toe gout. She had an I&D of the left great toe on 6/11/21 in order to decompress the underlying material/fluid. She presents weight bearing in her regular shoes. She notes that she is getting along well.
Physical Exam
Patient is a 78-year-old female.
Neurovascular status unchanged. Granular healing is noted to the open wound to the medial aspect of the left great toe. The base of the wound is a mix of granular and fibrotic tissue. No further tophaceous material or purulence is expressed from the wound region.
Procedure Documentation
EE Wound Debridement:Manual debridement of the wound was performed with sharp and blunt instrumentation.EE wet to dry:Sterile instrumentation was used to debride the wound down to a level of primarily healthy granular tissue. A wet-to-dry dressing was then applied over top the open wound area. The patient tolerated the procedure well. They were educated on proper application and changing instructions.
Assessment / Plan
Today I manually debrided the wound with sterile instrumentation down to healthy granular tissue. The wound was packed with Iodoform dressing followed by a dry bandage. She will continue to perform daily dressing changes to the open wound region. Follow up in 1 week for recheck of the wound, however she knows to call sooner if any concerns arise. Patient states she understands and agrees with the above recommendations. Today all questions have been answered.
1. Open wound of left foot
S91.302D
HPI
Rose presents to the office today for a followup on her left great toe gout. She had an I&D of the left great toe on 6/11/21 in order to decompress the underlying material/fluid. She presents weight bearing in her regular shoes. She notes that she is getting along well.
Physical Exam
Patient is a 78-year-old female.
Neurovascular status unchanged. Granular healing is noted to the open wound to the medial aspect of the left great toe. The base of the wound is a mix of granular and fibrotic tissue. No further tophaceous material or purulence is expressed from the wound region.
Procedure Documentation
EE Wound Debridement:Manual debridement of the wound was performed with sharp and blunt instrumentation.EE wet to dry:Sterile instrumentation was used to debride the wound down to a level of primarily healthy granular tissue. A wet-to-dry dressing was then applied over top the open wound area. The patient tolerated the procedure well. They were educated on proper application and changing instructions.
Assessment / Plan
Today I manually debrided the wound with sterile instrumentation down to healthy granular tissue. The wound was packed with Iodoform dressing followed by a dry bandage. She will continue to perform daily dressing changes to the open wound region. Follow up in 1 week for recheck of the wound, however she knows to call sooner if any concerns arise. Patient states she understands and agrees with the above recommendations. Today all questions have been answered.
1. Open wound of left foot
S91.302D