Regina Posted Tue 24th of April, 2012 14:47:35 PM
Patient presnts to ED after car accident with abrasions. Would this procedure be included in E/M or separate procedure?
Note reads: I used normal saline and sur-clens to remove initial blood, dirt and debris. Then the patient had LET placed over the area. After this had been in place 30 min., I thoroughly cleansed the area with betadine infused brush. Then areas of dead skin were removed. I then applied LET and scrubbed the wounds with a second betadine scrub brush. The wound was thoroughly rinsed with NS and sterile water. It was gently dried and then 3 xeroform dressings were placed over the wounds and abrasions. Then 3 non-stick bandages were placed over the xeroform and Kling roll gauze was placed over these. I did use 3- 2 inch long 2 inch silk tape to hold these in place.
SuperCoder Answered Tue 24th of April, 2012 19:24:56 PM
E/M seems most likely. There doesn't appear to be enough info to support a debridement code, for example.