Question

PREOPERATIVE DIAGNOSIS: Ischial pressure ulcer with massive ischioperineal and buttock sinus.

POSTOPERATIVE DIAGNOSIS: Same.

FINDINGS: There was a 2 cm open surgical ulcer extending down and connecting with an 8 × 30 cm diameter granulation-lined sinus cavity.

SURGICAL PROCEDURE: Excision of left ischial ulcer with total excision of 8 × 30 cm sinus of the buttock, perineal, and ischial areas.

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: 400 ml.

FLUIDS: 2 liters Ringer’s lactate.

DRAINS: None. COMPLICATION: None.

SPONGE AND NEEDLE COUNTS: Correct.

DESCRIPTION: The patient was intubated and turned in the right lateral decubitus position. I injected about 10 ml of 1% Xylocaine with 1 : 100,000 epinephrine around the surface ulcer, and made incisions down to the granulation tissue, keeping this intact. I opened the skin over the extent of the sinus tracts proximally and distally, trying to keep this in line with a potential Y-V advancement flap, and with some difficulty and remarkable bleeding around what appeared to be the sacrum, I was able to remove virtually intact the entire ulcer, covered with chronically infected granulation tissue. This granulation tissue was poor quality and had an unhealthy appearance. A piece of this was dropped in a culture tube as was a piece of what appeared to be the sacrum, which was quite sclerotic and consistent with an osteomyelitis of the sacrum. Following this extensive removal of the ulcer, I cauterized all of the bleeding and did a stick-tie on one of the bleeders with 2-0 Vicryl. I then sprayed the base with topical thrombin, packed the wound open with 2-inch vaginal packing soaked in 5/10th percent metronidazole, and then put several #2 Prolene sutures to keep the packing in place and to help seal off the wound from the fecal contamination. I put a Vi-Drape over this and then dressed it with Kerlix fluffs, ABD pads, and Elastoplast. The patient tolerated the procedure well and left the area in good condition

Using the CPT and ICD-10-CM manuals, indicate the modifier and the code that would be reported.

Answer 1

CPT is Current Procedural Terminology . It is a standardized classification system for reporting medical procedures and services indicated with specific "codes".

The CPT code for excision of left ischial ulcer with total excision of 8 × 30 cm sinus of the buttock, perineal, and ischial areas is 15940.

ICD -10 code for Ischial pressure ulcer with massive ischioperineal and buttock sinus is L89.329

The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is a system used by doctors and other healthcare providers to classify and code all diagnoses, symptoms and procedures in the United States.

Code 97597 is a wound care management code that involves serious wounds requiring extensive debridement .