SCHMITT93
New
I am new to Podiatry coding. I need help with this operative report. I was going to use CPT 97597 for the wound debridement but am really confused with the synthetic skin graft. He doesn't mention how big the skin graft was. I would appreciate any help.
Thank you.
Shelby
I have put the operative report below.
Preoperative Diagnosis:
1. Full-thickness wounds deep to tendon, right posterior leg
2. Cellulitis, right leg
Postoperative Diagnosis:
1. Full-thickness wounds deep to tendon, right posterior leg
2. Cellulitis, right leg
Procedure:
Wound debridement deep to tendon with partial excision of achilles tendon and application of synthetic skin graft.
Procedure in Detail:
The patient was brought to the operating room under mild sedation and placed under general anesthesia. The patient was then placed prone on the operating table. Approximately 10 ml of 0.5% Marcaine with epinephrine was injected about the patient's right posterior leg. The limb was then scrubbed,prepped,draped in the usual aseptic manner. Attention was then directed to the posterior leg where all necrotic and nonviable tissue was debrided from the wound. The wound was explored to take care that there were no areas of purulence deep to the tendon and none were found. Approximately of 1 L of normal sterile saline and bacitracin solution was utilized to cleanse the wound in a pulse lavage fashion. The synthetic skin graft was then placed over the wound and stapled to the wound to create good approximation. The edges were trimmed to fit the wound. Dry sterile dressing consisting of Silverlon, 4x4's, Kerlix, cast padding, and fiberglass rolls was applied to the patient's right leg.
The patient tolerated the procedure and anesthesia well. She transferred from the operating room to the PACU with vital signs stable, and neurovascular status intact tot he right foot. After a short period of postoperative monitoring, she will be discharged home.
Thank you.
Shelby
I have put the operative report below.
Preoperative Diagnosis:
1. Full-thickness wounds deep to tendon, right posterior leg
2. Cellulitis, right leg
Postoperative Diagnosis:
1. Full-thickness wounds deep to tendon, right posterior leg
2. Cellulitis, right leg
Procedure:
Wound debridement deep to tendon with partial excision of achilles tendon and application of synthetic skin graft.
Procedure in Detail:
The patient was brought to the operating room under mild sedation and placed under general anesthesia. The patient was then placed prone on the operating table. Approximately 10 ml of 0.5% Marcaine with epinephrine was injected about the patient's right posterior leg. The limb was then scrubbed,prepped,draped in the usual aseptic manner. Attention was then directed to the posterior leg where all necrotic and nonviable tissue was debrided from the wound. The wound was explored to take care that there were no areas of purulence deep to the tendon and none were found. Approximately of 1 L of normal sterile saline and bacitracin solution was utilized to cleanse the wound in a pulse lavage fashion. The synthetic skin graft was then placed over the wound and stapled to the wound to create good approximation. The edges were trimmed to fit the wound. Dry sterile dressing consisting of Silverlon, 4x4's, Kerlix, cast padding, and fiberglass rolls was applied to the patient's right leg.
The patient tolerated the procedure and anesthesia well. She transferred from the operating room to the PACU with vital signs stable, and neurovascular status intact tot he right foot. After a short period of postoperative monitoring, she will be discharged home.
