Wiki Wondering what the dx would be

[Deadpd]

Six months ago, a pt had an open quadriceps tendon repair revision. Pt came in and had an excisional debridement down to the bone due to increased swelling. Cultures were obtained including soft tissue, and a sinus tract and the bone which did have gross purulence. The facility is coding it with S76.122D. Would that be correct? Or would I need to add a complication code due to the infection? Plus should I wait for the pathology report to come back before we submit this?

Thanks!!

 

[kmdnine]

Query the physician to see if you can include osteomyelitis M86.4* or other osteomyelitis/soft tissue infection that will better justify the procedure(s). You might not need to wait for the path.

 

[amyjph]

It's not just S76.122D. That does not give the full story, plus if taking a patient for surgery it would not be the D character. It is at least A initial (active treatment). But that dx is not correct anyway. This is a complication or probably infection/osteomyelitis as suggested above. Was the wound closed or disrupted/non-healing? Would need to see the redacted op note, what did the provider list as the post-op dx? I would wait for path. Did they do intra-op path or cultures? It's probably going to end up being a T code such as T81.4___ or T81.3___ and then whatever the path states such as MSSA MRSA, streptococcus, etc. Possibly M86.1__
Additionally, if the patient was noncompliant following surgery and smoked, walked on the leg too soon, etc. or has comorbidities such as diabetes, CKD. Are there SDH that come into play, is the patient homeless, food access issues, problems obtaining medical care, language barrier, etc.? Of course, this would all have to be documented by the provider.
Think about it this way, does only using S76.122D tell the full story of why they did this case and the CPT that will be billed? No.

 

[Deadpd]

Thanks amyjph. I know there was much more to this chart than just what the doctor put on the op report. Just really needed some validation as to why I haven't coded it and sent it out. Many of these surgeons like to put as little as possible in their op reports, which really makes it difficult at times to give a proper diagnosis. And getting them to answer a query many times is like herding cats.
I appreciate all the feedback I get from here! So very informative and helpful!

 

[amyjph]

Thanks amyjph. I know there was much more to this chart than just what the doctor put on the op report. Just really needed some validation as to why I haven't coded it and sent it out. Many of these surgeons like to put as little as possible in their op reports, which really makes it difficult at times to give a proper diagnosis. And getting them to answer a query many times is like herding cats.
I appreciate all the feedback I get from here! So very informative and helpful!

I know and feel your pain. LoL