peporter
Guru
Hello coders, I know this will sound stupid but here I go. The surgeon coded an I&D using 27603 and I think it should be 11043. Please check his op note to see if I'm missing something that indicates this was drainage and not debridement. I'm always hesitant to change a code he has chosen. Thanks, Paula
PROCEDURES
1. Adjacent tissue transfer left lateral lower extremity wound with
closure 12 x 2 cm, 14021.
2. Left knee arthroscopy with synovectomy, 29876.
3. Incision with debridement left lower extremity medial wound 30 x 10
cm, 27603.
4. Incision with debridement left lower extremity lateral wound 12 x 2
cm, 27603.5. VAC placement left medial lower extremity wound 30 x 10 cm.
INDICATIONS
The patient is a 50-year-old male who was seen previously at Doctors
Hospital as a consultation. The patient, by history, had an abscess of
his left lower extremity and had an incision and debridement by
Podiatry. He is an end-stage renal patient. This did grow out
bacteria. The patient's wounds were packed with wet-to-dry dressing
changes by Podiatry. They were quite large wounds. There was question
about a knee infection. The patient had pain with range of motion of
his knee. There was an attempted aspiration by the orthopedic resident
but there was no fluid that could be drained. An MRI was taken which
showed a knee joint effusion. There was no abscess around the knee.
The large lower extremity wounds had necrotic tissue that needed a
repeat debridement. The decision was made to do an arthroscopy of the
knee to rule out infection of the knee joint as well. Risks, benefits
and complications were reviewed and appropriate consent was obtained.
The patient agreed to proceed with the surgery.
PROCEDURE
The patient was seen in preop holding by Departments of Orthopedics and
Anesthesia at which time he identified the left lower extremity as the
appropriate extremity for the procedure. I placed my initials on the
extremity for identification. He was receiving IV antibiotics on the
floor. He was taken back to the OR suite and placed supine on a
well-padded table. Placed under general anesthesia without
complication. A well-padded tourniquet was placed on the left upper
thigh. The extremity was sterilely prepped and draped in normal
fashion.
The first part of the procedure was the arthroscopy. We covered up the
lower extremity open wounds with sterile dressing and Esmarch bandage.
This left the knee exposed only. We did not want to contaminate the
knee. The standard inferomedial and inferolateral portals were created
sharply with a knife through skin. Blunt trocar and cannula were placed
in the inferolateral portal and suprapatellar pouch was entered. There
was a significant amount of synovitis and erythema in the knee. Shaver
was placed in the inferomedial portal and a synovectomy was completed in
the suprapatellar pouch, medial and lateral compartments. Once this was
completed, the articular cartilage could be seen. The patellofemoral
joint was without any lesions. The medial and lateral gutters were
entered. There was no abnormality. Femoral notch was inspected and the
ACL and PCL were intact. The medial and lateral compartments were
entered and the cartilage and meniscus looked good. There were no
cartilage lesions or tears. There were no signs of infection at this
point. The knee was washed out. The only thing that could be found was
significant synovitis that was debrided. The instruments were
withdrawn. Portals were closed with suture. A sterile dressing was
placed around the knee.
The lower extremity wounds then could be opened. The medial wound was
very large. This was almost down to bone. This involved skin,
superficial tissue, deep fascia and muscle. Necrotic skin was seen at
the edges. The knife was used to debride off and excise all of the
necrotic skin edges. The lateral wound did not look as bad. A knife
was used to excise some of the necrotic skin there. The tissue looked
much more viable. There was no gross pus. Curettes were used to
debride both wounds. Copious amounts of pulse lavage irrigation was
used to irrigate out both wounds. Once good healthy tissue could be
seen, the lateral wound was undermined and adjacent tissue transfer
could be done so that the incision could be closed.The skin edges were
brought together with 2-0 Vicryl intradermally. Staples were placed on
the skin. The medial wound could not be closed. Wound VAC sponges were
placed in the wound and then a wound VAC was applied to suction. The
patient did have a plantar ulcer which was not very deep which was being
handled by Podiatry. Wet-to-dry dressing changes were placed on this.
An Ace bandage was then placed from the foot up to the thigh. The
patient was then awoke from anesthesia without complication and
transferred to post anesthesia care in stable condition.
PROGNOSIS
The patient did not have an infection of his knee. He did have
significant synovitis. This was debrided out. His lateral wound was
able to be closed. This was without much tension. Adjacent tissue
transfer was completed on this with the closure. A wound VAC had to be
used on the medial side. The lateral wound measured 12 x 2 cm. The
medial wound measured 30 x 10 cm. The medial wound was quite large. I
did get a good debridement. The wound VAC will be used and changed
every 3 days until the wound has healed. The patient is an end-stage
renal patient and his prognosis is somewhat guarded. He will continue
IV antibiotics per Infectious Disease.
PROCEDURES
1. Adjacent tissue transfer left lateral lower extremity wound with
closure 12 x 2 cm, 14021.
2. Left knee arthroscopy with synovectomy, 29876.
3. Incision with debridement left lower extremity medial wound 30 x 10
cm, 27603.
4. Incision with debridement left lower extremity lateral wound 12 x 2
cm, 27603.5. VAC placement left medial lower extremity wound 30 x 10 cm.
INDICATIONS
The patient is a 50-year-old male who was seen previously at Doctors
Hospital as a consultation. The patient, by history, had an abscess of
his left lower extremity and had an incision and debridement by
Podiatry. He is an end-stage renal patient. This did grow out
bacteria. The patient's wounds were packed with wet-to-dry dressing
changes by Podiatry. They were quite large wounds. There was question
about a knee infection. The patient had pain with range of motion of
his knee. There was an attempted aspiration by the orthopedic resident
but there was no fluid that could be drained. An MRI was taken which
showed a knee joint effusion. There was no abscess around the knee.
The large lower extremity wounds had necrotic tissue that needed a
repeat debridement. The decision was made to do an arthroscopy of the
knee to rule out infection of the knee joint as well. Risks, benefits
and complications were reviewed and appropriate consent was obtained.
The patient agreed to proceed with the surgery.
PROCEDURE
The patient was seen in preop holding by Departments of Orthopedics and
Anesthesia at which time he identified the left lower extremity as the
appropriate extremity for the procedure. I placed my initials on the
extremity for identification. He was receiving IV antibiotics on the
floor. He was taken back to the OR suite and placed supine on a
well-padded table. Placed under general anesthesia without
complication. A well-padded tourniquet was placed on the left upper
thigh. The extremity was sterilely prepped and draped in normal
fashion.
The first part of the procedure was the arthroscopy. We covered up the
lower extremity open wounds with sterile dressing and Esmarch bandage.
This left the knee exposed only. We did not want to contaminate the
knee. The standard inferomedial and inferolateral portals were created
sharply with a knife through skin. Blunt trocar and cannula were placed
in the inferolateral portal and suprapatellar pouch was entered. There
was a significant amount of synovitis and erythema in the knee. Shaver
was placed in the inferomedial portal and a synovectomy was completed in
the suprapatellar pouch, medial and lateral compartments. Once this was
completed, the articular cartilage could be seen. The patellofemoral
joint was without any lesions. The medial and lateral gutters were
entered. There was no abnormality. Femoral notch was inspected and the
ACL and PCL were intact. The medial and lateral compartments were
entered and the cartilage and meniscus looked good. There were no
cartilage lesions or tears. There were no signs of infection at this
point. The knee was washed out. The only thing that could be found was
significant synovitis that was debrided. The instruments were
withdrawn. Portals were closed with suture. A sterile dressing was
placed around the knee.
The lower extremity wounds then could be opened. The medial wound was
very large. This was almost down to bone. This involved skin,
superficial tissue, deep fascia and muscle. Necrotic skin was seen at
the edges. The knife was used to debride off and excise all of the
necrotic skin edges. The lateral wound did not look as bad. A knife
was used to excise some of the necrotic skin there. The tissue looked
much more viable. There was no gross pus. Curettes were used to
debride both wounds. Copious amounts of pulse lavage irrigation was
used to irrigate out both wounds. Once good healthy tissue could be
seen, the lateral wound was undermined and adjacent tissue transfer
could be done so that the incision could be closed.The skin edges were
brought together with 2-0 Vicryl intradermally. Staples were placed on
the skin. The medial wound could not be closed. Wound VAC sponges were
placed in the wound and then a wound VAC was applied to suction. The
patient did have a plantar ulcer which was not very deep which was being
handled by Podiatry. Wet-to-dry dressing changes were placed on this.
An Ace bandage was then placed from the foot up to the thigh. The
patient was then awoke from anesthesia without complication and
transferred to post anesthesia care in stable condition.
PROGNOSIS
The patient did not have an infection of his knee. He did have
significant synovitis. This was debrided out. His lateral wound was
able to be closed. This was without much tension. Adjacent tissue
transfer was completed on this with the closure. A wound VAC had to be
used on the medial side. The lateral wound measured 12 x 2 cm. The
medial wound measured 30 x 10 cm. The medial wound was quite large. I
did get a good debridement. The wound VAC will be used and changed
every 3 days until the wound has healed. The patient is an end-stage
renal patient and his prognosis is somewhat guarded. He will continue
IV antibiotics per Infectious Disease.
