Frances Kirk
New
We need help in how to code this please: Provider wants a 12001 [Repair superficial wound <2.5cm]. Not sure that's correct. but not sure what else. E/M only doesn't seem enough. Thoughts?
73 year old male who presents for an open wound of the BIG TOE, LEFt foot, which occurred 2 hrs ago, while working in his shop. Pt says that he dropped a sheet of plywood 3/8" thick 4 ft x 8 ft, and it stopped on edge on the top of his foot. He notice pain immediately, now pain is gone. He has a tear in the toe nail. Washed in cold water. There is a laceration- (deep, full thickness) located on the dorsum of the toe at the nail bed, with nail plate raised .
LENGTH/DIMENSIONS: 2 cm long
BLEEDING STATUS: controlled.
DISTAL NEURO/VASCULAR/TENDON FUNCTION: normal.
RANGE OF MOTION: normal with FROM against resistance.
PROCEDURE:
--ANESTHETIC: 2% lidocaine w/o epinephrine and digital block
--WOUND PREP: --irrigated with saline per UCC protocol. Avulsed nail plate bed was returned to nail bed beneath the cuticle. Patient tolerated this well. Bleeding controlled. NAil secured to nailbed with steri strips.
--TYPE OF CLOSURE: steri-strips interrupted
--Good closure was obtained w/ good hemostasis.
--Discharge wound care consisted of a sterile dressing.
Here is the provider's response to our query:
This procedure is complicated, required a digital block, wound repair tools and a careful replacement of a lifted and disrupted nail base. (It is a skill that is much more complicated than "placing glue.") The most appropriate wound repair tool in this situation is the steri strip.
73 year old male who presents for an open wound of the BIG TOE, LEFt foot, which occurred 2 hrs ago, while working in his shop. Pt says that he dropped a sheet of plywood 3/8" thick 4 ft x 8 ft, and it stopped on edge on the top of his foot. He notice pain immediately, now pain is gone. He has a tear in the toe nail. Washed in cold water. There is a laceration- (deep, full thickness) located on the dorsum of the toe at the nail bed, with nail plate raised .
LENGTH/DIMENSIONS: 2 cm long
BLEEDING STATUS: controlled.
DISTAL NEURO/VASCULAR/TENDON FUNCTION: normal.
RANGE OF MOTION: normal with FROM against resistance.
PROCEDURE:
--ANESTHETIC: 2% lidocaine w/o epinephrine and digital block
--WOUND PREP: --irrigated with saline per UCC protocol. Avulsed nail plate bed was returned to nail bed beneath the cuticle. Patient tolerated this well. Bleeding controlled. NAil secured to nailbed with steri strips.
--TYPE OF CLOSURE: steri-strips interrupted
--Good closure was obtained w/ good hemostasis.
--Discharge wound care consisted of a sterile dressing.
Here is the provider's response to our query:
This procedure is complicated, required a digital block, wound repair tools and a careful replacement of a lifted and disrupted nail base. (It is a skill that is much more complicated than "placing glue.") The most appropriate wound repair tool in this situation is the steri strip.