I can't decide which code to use...11042,11045, or 12032, or 27301. There wasn't any infection, he didn't make an incision, looks like that he just debrided it and closed the wound. So I am leaning more toward 11042 & 11045. Can someone please help.
POSTOPERATIVE DIAGNOSIS: Right knee traumatic wound dehiscence, status
post fall and total knee arthroplasty.
PROCEDURE PERFORMED: Right knee irrigation and debridement with
primary wound closure.
INDICATIONS FOR PROCEDURE:
She tripped and fell and had a traumatic opening of the mid portion of her
incision of about 5 cm. She presented to the office yesterday with placing of sterile dressing. Advised
and recommended a formal irrigation and debridement with primary wound closure in the OR.
DESCRIPTION OF PROCEDURE: The patient was seen and evaluated in the preoperative suite.
Correct site was identified and marked. Preoperative antibiotics were given within one hour of surgical
incision. The patient was then brought to the operative suite. General anesthesia was induced.
Tourniquet was placed on the right lower extremity; however, it was not utilized for the case. The area
was then prepped and draped in the standard usual sterile fashion scrub and paint method. An Ioban was
placed over the extremity. Her mid portion of her incision of about 5 cm in length was debrided. We
attempted to aspirate her knee yesterday in the clinic. It was a dry aspirate. There was no effusion
whatsoever. After probing and inspecting the incision, there was no traumatic arthrotomy, did not seem to
communicate with the joint at all which was just a wound opening. So this was debrided with a curette
and we performed about 2 liters of pulse lavage irrigation. We then closed with 2-0 Monocryl and 2-0
nylon in a vertical mattress type fashion. Sterile Aquacel dressing was applied. The patient was awoken
and transferred to the PACU in stable satisfactory condition.
Any help will be greatly appreciated!! Thanks in advance!
POSTOPERATIVE DIAGNOSIS: Right knee traumatic wound dehiscence, status
post fall and total knee arthroplasty.
PROCEDURE PERFORMED: Right knee irrigation and debridement with
primary wound closure.
INDICATIONS FOR PROCEDURE:
She tripped and fell and had a traumatic opening of the mid portion of her
incision of about 5 cm. She presented to the office yesterday with placing of sterile dressing. Advised
and recommended a formal irrigation and debridement with primary wound closure in the OR.
DESCRIPTION OF PROCEDURE: The patient was seen and evaluated in the preoperative suite.
Correct site was identified and marked. Preoperative antibiotics were given within one hour of surgical
incision. The patient was then brought to the operative suite. General anesthesia was induced.
Tourniquet was placed on the right lower extremity; however, it was not utilized for the case. The area
was then prepped and draped in the standard usual sterile fashion scrub and paint method. An Ioban was
placed over the extremity. Her mid portion of her incision of about 5 cm in length was debrided. We
attempted to aspirate her knee yesterday in the clinic. It was a dry aspirate. There was no effusion
whatsoever. After probing and inspecting the incision, there was no traumatic arthrotomy, did not seem to
communicate with the joint at all which was just a wound opening. So this was debrided with a curette
and we performed about 2 liters of pulse lavage irrigation. We then closed with 2-0 Monocryl and 2-0
nylon in a vertical mattress type fashion. Sterile Aquacel dressing was applied. The patient was awoken
and transferred to the PACU in stable satisfactory condition.
Any help will be greatly appreciated!! Thanks in advance!