I'm interested in finding out how an experienced coder figures this one out!
11005 describes removal of skin, subq, muscle and fascia. 11042 would be used if all the deeper you went was subq. Did they specify whether muscle was included. I realize 10.5 is deep but some abdominal fat can be even deeper. From what I read, you group the wounds by depth but none of these is reported at same depth.
This is the OP note;
Specimen dimensions: Addendum
Left lower medial leg soft tissue portion 1 measures 15 x 11 x 4 cm with 13 x 6 cm skin
Left lower medial leg soft tissue portion 2 measures 21 x 10 x 6.5 cm with 23.5 x 6.7 cm of skin
Left lower medial leg soft tissue portion 3 measures 28 x 20.5 x 8 cm with 34.5 x 12 cm of skin
Right lower medial leg soft tissue measures 36.5 x 31.5 x 9 cm with 9.0 x 3.6 cm of skin as well as 30 x 23.5 cm of skin Left lateral thigh soft tissue measuring 38 x 30 x 10 cm with 15.2 x 21.5 cm of skin
Right anterior thigh soft tissue portion 1 measuring 15 x 7.5 x6 cm and portion 2 measuring 6 x 5.5 x 1.5 cm with greater than 13 x 7 cm skin
Abdominal wall soft tissue measures 60 x 35 x 10.5 cm
POSTOPERATIVE DIAGNOSES
1. Necrotizing wounds with superimposed infection of bilateral medial calves,
left hip, right anterior thigh, and abdominal wall.
2. Morbid obesity with a body mass index of 50.7 after debridement, but >60 on admission to XXX
3. Altered mental status secondary to toxic metabolic encephalopathy,
presumably secondary to sepsis.
4. Diabetes.
PROCEDURE: Debridement of necrotic, infected, skin and subcutaneous tissues from left lateral thigh, left medial lower leg, right medial lower leg, right anterior thigh, and abdominal wall.
SPECIMENS:
1. Right lower medial leg, 3095 g.
2. Abdominal wall, 4208 g.
3. Left lateral thigh, 3,654 g.
4. Right anterior thigh, 483 g.
5. Left lower medial leg, 2272 g of tissue.
FINDINGS: Included necrotic wounds with superinfection of the right and left medial thighs as well as the left hip and right anterior thigh and abdominal wall.
INDICATIONS FOR PROCEDURE: The patient is an unfortunate 38-year-old superobese female who was transferred to XXX XXXX in the middle of August for a necrotizing soft tissue infection of the abdominal wall. She underwent multiple debridements and subsequently had improvement in her wounds. However, after being transferred to the floor had required transfer back to the ICU for code met for sepsis. Examination of her wounds revealed evidence of purulence and bacterial superinfection. In combination with the patient's altered mental status, there was a very real concern that this represented an aggressive necrotizing soft tissue infection that would be rapidly fatal if not managed aggressively. Attempts to reach the patient's family were unsuccessful and the patient's altered mental status rendered her unable to consent.
PROCEDURE IN DETAIL: The patient was brought to the operating room and placed on the operating room table in supine position. Sequential compression hose were unable to be placed on her lower extremities due to the location of the wounds. Therefore, blood pressure cuff being cycled frequently was placed on her arm. Care was taken to prep and drape the patient in the best fashion we could. Appropriate IV antibiotics were administered per SCIP protocol. The abdomen, both legs, and hip were prepped and draped into the field in the usual sterile fashion. After call to order was performed, we began debriding the necrotic tissue using a combination of Bovie electrocautery and LigaSure for hemostasis. Unfortunately, there was poor perfusion to all of this adipose tissue with very little bleeding despite aggressive debridement. We did our best to debride back to viable tissue and to excise all of the necrotic portions of the wound. After debridement was complete and the specimens were passed off the field for pathology and culture, we then proceeded to copiously irrigate all the wounds using IrriSept solution and to ensure hemostasis. Our WOCN colleagues did come to the operating room to assist us with dressing these large wounds and this was performed very carefully. After irrigating with IrriSept, it was decided that in order to manage the fluid sequestration from these wounds, negative pressure dressings would be required. Due to the patient's sepsis after incising and draining these infected necrotic wounds, it was elected to leave her intubated due to her vasopressor requirement, but also because her dressing changes would likely require anesthesia. The patient was taken back to the Intensive Care Unit at the completion of the procedure, intubated, and requiring a significant amount of vasopressor support. This patient remains critically ill with a poor prognosis.
