As Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding continue to grow and become common practice it is important for not just coders, but also our clinicians to recognize its importance and the effect it has on reimbursement. Below is an example of a procedure and notes regarding coding and why our clinician must be queried in order for the claim to be submitted. Do you have a complicated surgery case that needs help with coding? RT Welter would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. RT Welter will not use any medical records submitted in which PHI is not removed and protected. – Click Here to Submit Redacted Surgery Case Study –
DATE OF SURGERY: XX/XX/19
PREOPERATIVE DIAGNOSIS: Left foot necrosis, as well as heel ulcer. PROCEDURES:
- Left foot transmetatarsal amputation.
- Left foot heel debridement, extensive.
NOTE: Documentation gives the impression that PT may have DM. Per correct coding guidelines, in order to code for peripheral vascular disease, we need to know if this is in relation to a Dx of diabetes mellitus as it effects code selection. Also, in order to code for heel debridement, surface area and depth must be documented (code 11043 can be reported and possibly 11046 if applicable).
POSTOPERATIVE DIAGNOSIS: Same.
ASSISTANT: A. SMITH, SA-C.
ANESTHESIA: Peripheral nerve block with MAC. ESTIMATED BLOOD LOSS: 25 mL.
INTRAVENOUS FLUIDS: One L crystalloid. SPECIMENS REMOVED: Foot sent to path. COMPLICATIONS: None.
DISPOSITION: To recovery room in good condition.
FINDINGS: The patient was found to have left near full-thickness heel ulcers with no exposed bone. She also had necrosis of the entire forefoot.
INDICATIONS: This is a 55-year-old female, with extensive peripheral vascular disease, who was deemed a surgical candidate for the stated procedure. Risks and benefits were discussed at length with the patient, including, but not limited to, infection, bleeding, neurologic injury, vascular injury, pain, stiffness, a possible need for further surgery. I personally marked the patient’s operative extremity prior to proceeding forth to the operating room.
OPERATIVE REPORT: The patient was brought to the operating room on a gurney. She underwent peripheral nerve block per the anesthesia service. She was placed in the supine position and underwent MAC anesthesia. The left lower extremity was sterilely prepped and draped, using pure alcohol scrub and ChloraPrep.
Following timeout confirming the correct patient, procedure, and extremity, the heel ulcer wounds were debrided. These were through the fascial layer, but not down to the bone. These were debrided back to bleeding tissue.
We then performed a transmetatarsal amputation by making a skin incision along viable skin. The subcutaneous tissues were stripped back to a planned osteotomy site with an oscillating saw. There was osteotomy performed along the proximal metatarsals. The specimen was sent to the path lab. We then checked for bleeding. There was bleeding at this level. This was irrigated out with 3 L normal saline mixed with bacitracin. Then with no tension, the plantar fat pad was repaired to the metatarsals. The skin was closed with 2-0 Monocryl and 2-0 nylon along with no tension. A sterile dressing was placed. The patient was then extubated and brought to the recovery room, with no further complications.
Please note that A. SMITH, SA-C, a skilled surgical assist, was an absolute requirement due to the complexity of this procedure. He did participate in wound exposure, retraction, and closure at the conclusion of the case.