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The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777 Exercise 2
Case 5-2
Assign an external cause to indicate how the injury occurred.
OPERATIVE REPORT
LOCATION: Outpatient, Hospital
PATIENT: Ray Darwin
PRIMARY CARE PHYSICIAN: Eugene Hightower, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Traumatic amputation of tip of right middle finger.
POSTOPERATIVE DIAGNOSIS: Traumatic amputation of tip of right middle finger.
PROCEDURE PERFORMED: Volar V-Y advancement flap, right middle finger.
ANESTHESIA: 0.5% Marcaine local metacarpal block.
PREOPERATIVE NOTE: The patient sustained an injury yesterday when he partially amputated his dominant right middle fingertip, which was caught between a dock and a boat as a wave rocked the boat at the lake. He was seen at the local emergency room, he was given a tetanus booster, and the wound was dressed. He is scheduled for V-Y advancement flap to the finger today. He is originally from Manytown and will be having follow-up care from his family physician, Dr. Hightower.
After full discussion with the patient, he elects to proceed with this skin flap today.
PROCEDURE: The patient was brought to the operating room, and a metacarpal block was induced with 10 cc of 0.5% Marcaine. The dressings were removed from the right middle finger, and the right upper extremity was prepped with Betadine and draped in a sterile fashion. A digital tourniquet was applied to the finger for approximately 25 minutes. With 4× magnification loupes, we debrided the finger in the area of the amputation, which was at the distal end of the sterile nail matrix. About two thirds of the sterile nail matrix and the entire germinal matrix were still present, but the nail plate was absent. Most of the volar pad was still intact. There was about 3 to 4 mm of distal tuft of the distal phalanx that was absent. However, the wound was extremely clean. We lightly debrided it and removed blood clots. We thoroughly irrigated with sterile saline. We then fabricated a volar V-Y advancement flap back to the distal interphalangeal joint flexor crease. We then moved this flap distalward and advanced it about 5 to 6 mm. We then sutured this directly to the nailbed with interrupted 5-0 Vicryl sutures and closed this up along its margins with interrupted 5-0 nylon sutures. The appearance was excellent. We then placed Xeroform into the nailbed proximally to prevent adhesions. We then removed the digital tourniquet, and excellent circulation returned to the fingertip, including vascular blood in the graft. We then applied Xeroform over the wounds with light gauze dressings, TubeGauz, and light Coban. The patient tolerated the procedure well. He will be dismissed as an outpatient today. He will complete his fishing trip and return to Manytown in 2 or 3 days, and he will follow up with his home physician, Dr. Hightower. (Note that Dr. Sanchez provided only the surgical service.) Patient has been placed on Keflex 500 mg p.o. q.i.d. for 5 days. We also gave him a prescription for Lorcet, 30 tablets.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. Was the skin repair a free flap or an adjacent tissue transfer? _________________
2. What modifier is required to indicate that only the intraoperative portion of the service was/will be provided? _________________
3. What other modifier would be appropriate? _________________
4. Which modifier is reported first? _________________
Assign an external cause to indicate how the injury occurred.
OPERATIVE REPORT
LOCATION: Outpatient, Hospital
PATIENT: Ray Darwin
PRIMARY CARE PHYSICIAN: Eugene Hightower, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Traumatic amputation of tip of right middle finger.
POSTOPERATIVE DIAGNOSIS: Traumatic amputation of tip of right middle finger.
PROCEDURE PERFORMED: Volar V-Y advancement flap, right middle finger.
ANESTHESIA: 0.5% Marcaine local metacarpal block.
PREOPERATIVE NOTE: The patient sustained an injury yesterday when he partially amputated his dominant right middle fingertip, which was caught between a dock and a boat as a wave rocked the boat at the lake. He was seen at the local emergency room, he was given a tetanus booster, and the wound was dressed. He is scheduled for V-Y advancement flap to the finger today. He is originally from Manytown and will be having follow-up care from his family physician, Dr. Hightower.
After full discussion with the patient, he elects to proceed with this skin flap today.
PROCEDURE: The patient was brought to the operating room, and a metacarpal block was induced with 10 cc of 0.5% Marcaine. The dressings were removed from the right middle finger, and the right upper extremity was prepped with Betadine and draped in a sterile fashion. A digital tourniquet was applied to the finger for approximately 25 minutes. With 4× magnification loupes, we debrided the finger in the area of the amputation, which was at the distal end of the sterile nail matrix. About two thirds of the sterile nail matrix and the entire germinal matrix were still present, but the nail plate was absent. Most of the volar pad was still intact. There was about 3 to 4 mm of distal tuft of the distal phalanx that was absent. However, the wound was extremely clean. We lightly debrided it and removed blood clots. We thoroughly irrigated with sterile saline. We then fabricated a volar V-Y advancement flap back to the distal interphalangeal joint flexor crease. We then moved this flap distalward and advanced it about 5 to 6 mm. We then sutured this directly to the nailbed with interrupted 5-0 Vicryl sutures and closed this up along its margins with interrupted 5-0 nylon sutures. The appearance was excellent. We then placed Xeroform into the nailbed proximally to prevent adhesions. We then removed the digital tourniquet, and excellent circulation returned to the fingertip, including vascular blood in the graft. We then applied Xeroform over the wounds with light gauze dressings, TubeGauz, and light Coban. The patient tolerated the procedure well. He will be dismissed as an outpatient today. He will complete his fishing trip and return to Manytown in 2 or 3 days, and he will follow up with his home physician, Dr. Hightower. (Note that Dr. Sanchez provided only the surgical service.) Patient has been placed on Keflex 500 mg p.o. q.i.d. for 5 days. We also gave him a prescription for Lorcet, 30 tablets.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. Was the skin repair a free flap or an adjacent tissue transfer? _________________
2. What modifier is required to indicate that only the intraoperative portion of the service was/will be provided? _________________
3. What other modifier would be appropriate? _________________
4. Which modifier is reported first? _________________
Explanation
Verified
Verified
The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
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