Hi,
Could I please get some opinions on this? I'm not sure if I should code it as an I&D or a debridement and it doesn't really indicate HOW it was debrided. Thank you!
Date of Service: March 20, 2014
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS
Massive hematoma subcutaneous right leg.
POSTOPERATIVE DIAGNOSIS
Massive hematoma subcutaneous right leg.
ANESTHESIA
General.
PROCEDURE PERFORMED
Incision, drainage and debridement of hematoma right leg.
ESTIMATED BLOOD LOSS
The patient had 500 mL of clot.
COMPLICATIONS
None.
DRAINS
None.
PROCEDURE IN DETAIL
After adequate premedication, the patient was taken to the operating room and a general anesthetic by way of endotracheal ablation was carried out by the Anesthesia Department. The patient had been on Eliquis, an anticoagulant with a relatively short half life. Her last dose was yesterday morning. She developed a spontaneous bleed into the medial aspect of her right leg. We waited 24 hours and are taking her to the operating room for evacuation of the hematoma. The area was prepped and draped in a sterile fashion but, simply with elevating the leg, the skin disrupted and was debrided from the edges of the wound. We were left with a defect. It was probably 18 x 12 cm in diameter down to the subcutaneous tissue. There were 2 areas of slight oozing that were cauterized. Otherwise, there was no significant bleeding noted. The wound was covered with some Surgicel, an ABD, and then wrapped with a Kerlix and then the leg was gently wrapped with a 4 inch Ace bandage. She tolerated the procedure well and returned to the recovery room with stable vital signs.
Could I please get some opinions on this? I'm not sure if I should code it as an I&D or a debridement and it doesn't really indicate HOW it was debrided. Thank you!
Date of Service: March 20, 2014
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS
Massive hematoma subcutaneous right leg.
POSTOPERATIVE DIAGNOSIS
Massive hematoma subcutaneous right leg.
ANESTHESIA
General.
PROCEDURE PERFORMED
Incision, drainage and debridement of hematoma right leg.
ESTIMATED BLOOD LOSS
The patient had 500 mL of clot.
COMPLICATIONS
None.
DRAINS
None.
PROCEDURE IN DETAIL
After adequate premedication, the patient was taken to the operating room and a general anesthetic by way of endotracheal ablation was carried out by the Anesthesia Department. The patient had been on Eliquis, an anticoagulant with a relatively short half life. Her last dose was yesterday morning. She developed a spontaneous bleed into the medial aspect of her right leg. We waited 24 hours and are taking her to the operating room for evacuation of the hematoma. The area was prepped and draped in a sterile fashion but, simply with elevating the leg, the skin disrupted and was debrided from the edges of the wound. We were left with a defect. It was probably 18 x 12 cm in diameter down to the subcutaneous tissue. There were 2 areas of slight oozing that were cauterized. Otherwise, there was no significant bleeding noted. The wound was covered with some Surgicel, an ABD, and then wrapped with a Kerlix and then the leg was gently wrapped with a 4 inch Ace bandage. She tolerated the procedure well and returned to the recovery room with stable vital signs.