Kathy Posted Fri 06th of March, 2015 11:54:59 AM
Please advise appropriate diagnosis & procedure codes for the following situation: patient presents with a refractory wound of foot after recently treated/resolved cellulitis. A 15 blade was used to circumscribe margins of wound so that we could get to healthy normal dermis. There was a tremendous amount of scar tissue, fibrosis & chrnoic granulation tisue along the entire common extensor along the estnesor digitorum longus of the foot. I had to widely undermine skin flaps proximally & distally to allow for a tension-free closure at the end of the procedure. Once the flaps were elevated I spent approximately 20 mins. performing a very extensive tenosynovectomy to remove all the chronic granulation tissue which proesumable was coloized & contributed to her cellulitis. Using a 15 blade, littler scissors & a rongeur I was able to strip the long digit extensors of all pathologic tissue. There was also chronic granulation tissue at the base of the wound along the lateral capsule of the ankle. Once the sharp debridement was completed I passively flexed & extended the toes & demonstrated excellent excursion of the tendons w/no further entrapment. Three liters of antibiotic solution were then run through the wound via cysto tubing. Tourniquet was released & after meticulous hemostasis was confirmed I was then able to advance the proximal & distal skin flaps. She had a tremendous amount of inflammatory response to the vicryl sutures @ her initial surgery therefore I opted to close w/a single layer of 3-0 nylon interrupted sutures.
SuperCoder Answered Tue 10th of March, 2015 09:46:48 AM
Thank you for the query.
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail email@example.com for more information.