Hello all!
I'm having some issues with deciding whether or not to use the wound care codes. Can anyone give me a little detail on these codes. For example below is are notes for wound debridement. Would I go with the codes in the 10000s or would I use the would care codes in the 90000s. Any help will greatly be appreciated.
NAME OF PROCEDURE: Local wound debridement and delayed primary closure.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old female with history of PEG
tube placement with erosion of PEG tube site. She underwent gastrocutaneous
fistula take down and new PEG tube placement earlier in her hospitalization;
however, she has had dehiscence of her wound at the gastrocutaneous fistula
site. This was felt to be amenable to local wound debridement and delayed
primary closure.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the son and all
questions were answered. The patient was brought back to the operating room
suite and induction of anesthesia with general anesthetic was performed. The
patient was prepped and draped in the usual sterile fashion. A time-out was
then performed, verifying correct patient, site, procedure and signature of
informed consent. The wound was inspected and minimal amount of necrotic
debris was evident at the edges of the wound as well as the base of the wound.
This was sharply debrided using a 10-blade scalpel until fat and a minimal
amount of bleeding was identified.
The wound was then inspected for adequate hemostasis and the decision was made
at that time to proceed with delayed primary closure. PDS suture was used to
close the wounds in a simple interrupted fashion with a total of 6 simple
interrupted sutures being placed. The wound was inspected for adequate
hemostasis and when this was determined to be the case, the procedure was then
concluded. The wound was dressed with Primapore tape. The patient was
withdrawn from anesthetic. The patient was transferred back to the ICU in
stable condition.
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Need help with wound code