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Bleeding Tracheotomy Wound

Susan m Posted Fri 26th of June, 2015 09:56:52 AM

Could you please help me with this op report:

Diagnosis: Bleeding Tracheotomy Wound
Operation: Exploration of Tracheotomy Wound with Control of Bleeding

Patient was bleeding profusely from his tracheotomy site. His tracheotomy tube was removed. Arterial bleeding was noted to be coming from the inferior right side of the tracheotomy wound near the trachea. Bleeder was controlled with a bipolar cautery. A size 70 tracheotomy tube was inserted. The tube was secured to the wound with four sutures of 2-0 Prolene and dressing applied.

What DX and CPT code wound be appropriate?

Thanks so much!

SuperCoder Answered Mon 29th of June, 2015 00:41:49 AM

AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) ( for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.

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