Question

Progress Note

HISTORY OF PRESENT ILLNESS: This patient was been previously seen by me four months prior for a very complicated injury to her right fourth digit. On today’s visit, she comes in with an area, which she states has been draining pus, painful on the dorsal aspect just proximal to her DIP joint.

PHYSICAL EXAMINATION: The overall repairs from her previous injury were evaluated. They were all intact. As expected, she has had some stiffness of the DIP joint but did have near full extension compared to the other side and has some flexion. We are still working on her range of motion. On this visit, on physical exam, the patient had a firm foreign body embedded into the dorsal aspect near the insertion of the extensor tendon where she had some bone involvement with her previous injury.

ASSESSMENT/PLAN: After thorough evaluation and management, the decision was made for surgical intervention. The patient had a post operative granuloma, which was causing some infection and drainage involving the dorsal aspect of the digit and the extensor tendon.

PROCEDURE: After sterile preparation, draping, and using a sterile suture tray, an incision was made. After extensive exploration, the foreign body was retrieved. It was a bony fragment with other suture material associated with it. This was removed. The repair using the permanent suture of the proper extensor tendon was not exposed. The suture material removed from the flap repair with some PDS suture and some bony fragments. After these were removed, the wound was cleansed, covered with antibiotic ointment, and dressed appropriately.

ASSESSMENT/PLAN: Evaluation and management of the injury outside of the global period was done initially, and a decision was made for separate operative procedure, which was removal of a granuloma and debridement of skin, soft tissue, and bone. The material removed was suture material, skin, subcutaneous tissue, and even bony fragments all from the depths of the wound and associated with the previous fracture.

The patient tolerated the procedure well. If she continues to have a persistent problem, a larger incision will be required and the entire nonabsorbable suture repair of the extensor tendon will require attention also. I think this is an unlikely scenario; however, further exploration would not be indicated or ideal at this time. Patient will be placed on antibiotics and will follow up if she has any problem or if there is not complete healing within the next 2 weeks. This was all discussed with her in detail.

1. FILL IN THE BLANK.
   Enter the proper code(s) in the blank(s) provided. If a specific category of code is not applicable please leave the box blank. When entering multiple codes in the same box separate them with a comma and a space (i.e. E11.9, I10).
   1. Primary ICD-10-CM Code:
   2. Secondary ICD-10-CM Code(s):
   3. Z Code(s):
   4. External Cause of Morbidity Code(s):
   5. Primary CPT Code:
   6. Secondary CPT Code(s):
   7. HCPCS Code(s):

Answer 1

1, primary ICD-10-cm code

Cutaneous abscess of right hand L02.511

2 , secondary ICD-10-CM code

Foreign body old or residual M 79.5

3, Z code:

Z codes represents the reasons for encounter

Encounter for removal of sutures Z48.02

4, External cause of morbidity code:

Granulation formation of wound after surgery T81.89

5, primary CPT code

Incision and removal of foreign body associated with open fracture skin, subcutaneous tissue, muscle fascia, muscle and bone 11012

6, secondary CPT code : not done

7, HCPCS code

Zero to 10days global period after the procedure applies

Modifier 58 staged Or related procedure or services by the same Physician during the post operative period.