vmounce
Guru
Can someone look over this op note below? Doctor's office says to use 20670 and 27610. My bundling program shows it is bundled. Would it be correct to code this way if it is in the “SAME INCISION”?
I appreciate any info.
Vickie
PREOPERATIVE DIAGNOSIS: Abscess of left ankle with migrating hardware, possible septic arthritis.
POSTOPERATIVE DIAGNOSIS: Abscess with septic arthritis, left ankle.
PROCEDURE: Hardware removal and extensive debridement of soft tissue and arthrotomy lavage of the left ankle joint and packing.
INDICATIONS: This is a 37-year-old female who had an ORIF on May 26, 2010 for a bad trimalleolar fracture of her ankle. She did fine postoperatively but over the last three to four weeks, she started to present with swelling, redness, and puffiness anterior to the medial malleolus. On x-ray, one of the K-wires that was placed to hold a fragment of the medial malleolus fracture, had migrated under the skin and she started to develop two draining holes that were draining pus. She has a history of MRSA. She is here today for removal of the K-wire and also debridement and inspection of the wound.
OPERATIVE PROCEDURE: The patient underwent general anesthesia proceeded by prepping and draping of the left lower extremity. The tourniquet was inflated to 250 mmHg.
An elliptical incision was made to include both draining holes. The incision measured 4 cm. Then after I removed the skin, I could see the K-wire that came out easily. However, there is a tracking of purulent material going straight to the medial malleolus and ankle joint. I excised all that suspicious tissue and I used the rongeur to clean the subcutaneous space. I followed the tracking and excised the suspicious tissue around the tracking down to the ankle joint. The ankle joint is opened and washed out with normal saline.
After the wound is really cleaned, I sent the deep specimens for culture and sensitivity. We gave her 1 gram of Vancomycin preoperatively. I packed the wound with a quarter inch plain packing gauze. I closed the wound partially with Prolene 4-0. A sterile compressive dressing was applied. Local anesthesia was infiltrated for pain management postoperatively. The procedure was well tolerated. The tourniquet was deflated with good capillary refill.
I appreciate any info.
Vickie
PREOPERATIVE DIAGNOSIS: Abscess of left ankle with migrating hardware, possible septic arthritis.
POSTOPERATIVE DIAGNOSIS: Abscess with septic arthritis, left ankle.
PROCEDURE: Hardware removal and extensive debridement of soft tissue and arthrotomy lavage of the left ankle joint and packing.
INDICATIONS: This is a 37-year-old female who had an ORIF on May 26, 2010 for a bad trimalleolar fracture of her ankle. She did fine postoperatively but over the last three to four weeks, she started to present with swelling, redness, and puffiness anterior to the medial malleolus. On x-ray, one of the K-wires that was placed to hold a fragment of the medial malleolus fracture, had migrated under the skin and she started to develop two draining holes that were draining pus. She has a history of MRSA. She is here today for removal of the K-wire and also debridement and inspection of the wound.
OPERATIVE PROCEDURE: The patient underwent general anesthesia proceeded by prepping and draping of the left lower extremity. The tourniquet was inflated to 250 mmHg.
An elliptical incision was made to include both draining holes. The incision measured 4 cm. Then after I removed the skin, I could see the K-wire that came out easily. However, there is a tracking of purulent material going straight to the medial malleolus and ankle joint. I excised all that suspicious tissue and I used the rongeur to clean the subcutaneous space. I followed the tracking and excised the suspicious tissue around the tracking down to the ankle joint. The ankle joint is opened and washed out with normal saline.
After the wound is really cleaned, I sent the deep specimens for culture and sensitivity. We gave her 1 gram of Vancomycin preoperatively. I packed the wound with a quarter inch plain packing gauze. I closed the wound partially with Prolene 4-0. A sterile compressive dressing was applied. Local anesthesia was infiltrated for pain management postoperatively. The procedure was well tolerated. The tourniquet was deflated with good capillary refill.