Read the operative report and note the pathological diagnosis. Then perform the following steps in t. Question
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Read the operative report and note the pathological diagnosis. Then perform the following steps in the coding process. Record your results in the spaces provided. Principal Diagnosis: Open wound, left thigh, status post fasciotomy Procedure Performed: Split-thickness skin graft, left thigh, donor site from left thigh. Graft was approximately 12 cm x 5 cm. Description of Procedure: patient was is status post-trauma. A tree fell on him and he sustained a significant injury to his thigh. He had compartment syndrome of his thigh, requiring a fasciotomy. He presents today for a skin graft to the fasciotomy site. The patient was brought to the operating room and placed in supine on the operating table. Following the adequate induction of general anesthesia. His left thigh and fasciotomy site was prepped and draped in the standard fashion. Attention was first directed to the patient’s anterior thigh. The Betadine prep was gently removed with normal saline. We then applied mineral oil to the anterior thigh. We then used a dermatome to harvest an approximately 12-cm x 5-cm split-thickness skin graft in the depth of 0.015. Following removal of our donor site, an epinephrine-soaked sponge was applied to the donor site. We then went into the back table and meshed our graft 1:1. Following this, we prepared our graft bed for graft placement. The excellent granulation tissue bed was roughed up using a gauze sponge, and the skin graft was applied and secured in place using surgical staples. The edge of the skin was then trimmed accordingly. Following adequate placement and securing our graft, we then fashioned the dressing. A Bacitracin-coated Adaptic was then applied over the graft and Reston foam was applied over that. Fine mesh gauze was then used to secure it in place, and the Reston and mesh gauze were secured using surgical staples. There was excellent compression against the graft. Following this, we turned our attention to the donor site. Epinephrine-soaked gauze was removed and Calgiswab dressing was applied. There was excellent hemostasis from the donor site. Following this, a Kerlix roll was placed around the left thigh and secured with paper tape. The patient tolerated the procedure without complications. 1. What procedure was performed? 2. After reviewing the operative report, how many centimeters was the graft? 3. What code(s) does the index guide a coder to review? 4. Based on the information gathered from the operative report, what CPT code should be reported? CPT 5. Now, assume the skin graft was planned and repaired during the postoperative time of the fasciotomy and both procedures were performed by the same surgeon. What Modifier should be reported with the skin graft CPT? Modifier
SCIENCE
HEALTH SCIENCE
NURSING
MC165 165
Read the operative report and note the pathological diagnosis. Then perform the following steps in t
