abaer01
Contributor
Can someone please help with this?
"Indications: Patient underwent an ORIF of her right proximal humerus fracture 3 weeks ago and presented with a superficial dehicense of the middle portion of her surgical wound with some drainage.
Name of procedure: Right shoulder surgical site infections irrigation and debridement.
Description of procedure:
There was a superficial pocket with the subcutaneous tissue adjacent to one of the distal sutures. Proximally there was a small collection of purulent fluid. The fascia was not violated and there was no drainage from or connection to the joint.
The wound was irrigated with pulse lavage and 9 L of normal saline and 1 L of puracyn. Subcutaneous tissue was reapproximated with interrupted 2-0 PDS suture. Skin was closed with a 2-0 nylon in an interrupted horizontal mattress. The skin was cleaned and dried. Shoulder was dressed...etc., etc."
The provider wants to code as 11044, and I believe a secondary wound closure code such as 13160 is appropriate, however I feel the documentation is severely lacking. Is 11044 supported by the documentation in this case? I see no debridement of bone, or at all for that matter, nor do I see measurements. My thinking is that this should be coded as 11042 with 12020 once the measurements are added to the documentation.
Thank you!!
"Indications: Patient underwent an ORIF of her right proximal humerus fracture 3 weeks ago and presented with a superficial dehicense of the middle portion of her surgical wound with some drainage.
Name of procedure: Right shoulder surgical site infections irrigation and debridement.
Description of procedure:
There was a superficial pocket with the subcutaneous tissue adjacent to one of the distal sutures. Proximally there was a small collection of purulent fluid. The fascia was not violated and there was no drainage from or connection to the joint.
The wound was irrigated with pulse lavage and 9 L of normal saline and 1 L of puracyn. Subcutaneous tissue was reapproximated with interrupted 2-0 PDS suture. Skin was closed with a 2-0 nylon in an interrupted horizontal mattress. The skin was cleaned and dried. Shoulder was dressed...etc., etc."
The provider wants to code as 11044, and I believe a secondary wound closure code such as 13160 is appropriate, however I feel the documentation is severely lacking. Is 11044 supported by the documentation in this case? I see no debridement of bone, or at all for that matter, nor do I see measurements. My thinking is that this should be coded as 11042 with 12020 once the measurements are added to the documentation.
Thank you!!