Ortho resident performed debridement on a patient. I am thinking to use "11042debridement subcutaneous tissue 20 sq cm/< "code; however, a physician document only that the eschar was debrided sharply at the bedside.
Any feedback will be greatly appreciated.
thanks,
"right lower extremity is somewhat edematous compared with left. There are 2 wounds now on the lateral aspect of the right thigh. The superior one measures approximately 4 cm in diameter there is a necrotic rim to this lesion. There is no active drainage. The lower wound approximately 2 cm below the larger wound, measures approximately 3 cm in diameter. There is mild necrotic eschar at the periphery this wound is well. Upon probing of both wounds I entered a pocket from the superior wound that tracks superiorly and somewhat posteriorly to a depth of approximately 6 cm, this drained fluid consistent with seroma/fat necrosis. No frank pus. The surrounding eschar was debrided sharply at the bedside. The lower wound was also probed and a pocket was encountered which tracks inferiorly and posteriorly, draining similar fluid. The wounds were irrigated, and packed with a 1 inch Nu Gauze wick covered with a wet-to-dry dressing in the wound cavities and a Kerlix wrap."