patient presented with necrotizing fascitis. This is the first of three surgeries performed. Dictation states to fascia and muscle. I would love to use CPT 11004 11005 but it is not for extremities. I am not sure how to break down 11043 and 11046 to get to 120 cm. Any suggestions would be appreciate.

PREOPERATIVE DIAGNOSIS: Left arm abscess with concern for necrotizing soft tissue wound.
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POSTOPERATIVE DIAGNOSIS: Left arm necrotizing soft tissue wound.
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PROCEDURE: Left arm wound exploration measuring 25 x 10 x 4 cm with debridement of subcutaneous tissue and wound VAC placement.
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ANESTHESIA: General.
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SPECIMENS: Wound culture to microbiology.
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ESTIMATED BLOOD LOSS: Less than 50 mL.
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FINDINGS:
1. Small area of necrotic fat at the medial aspect of the left antecubital fossa and the area of gas collection on CT scan.
2. Diffuse edema throughout the soft tissue. No evidence of tracking infection along the fascia.
3. An area of induration to the contralateral arm (right arm antecubital fossa) was noted after the patient was then anesthetized. This was not fluctuant and no acute evidence of abscess. This is concerning for potential site of skin manipulation.
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INDICATIONS FOR PROCEDURE: The patient is a 31-year-old female who presented with severe onset of left arm pain over the past 48 hours. CT was obtained which revealed a gas collection at the medial aspect of the arm which was concerning for possible early necrotizing fasciitis. She had diffuse pain and edema to the upper and lower arm. Given these findings, surgical intervention was indicated. The risks, benefits and alternatives of procedure were discussed with the patient and she wished to proceed.
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DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating room theater. She was placed in supine position. General anesthesia was induced. Preoperative antibiotics were administered. The patient’s left arm was then prepped and draped in normal sterile fashion. A lazy S incision was made along the medial aspect of the upper arm and then extending laterally in the lower arm. This was done to be able to access the area of greatest concern with the gas collection along the medial aspect near the antecubital fossa. Dissection was carried down with electrocautery. There was diffuse edema that was then expressed immediately with the incision through the subcutaneous tissues. A combination of blunt and sharp dissection was utilized. She has an area of a necrotic-appearing fat at this medial aspect of the area of greatest concern on CT scan. There was diffuse edema to the subcutaneous tissue, but no evidence of infection tracking along the fascial compartments. The fascia overlying the biceps in the upper arm was opened. There was no significant muscle bulging or evidence of pressure within this compartment. This was done likewise in the forearm and again all the edema was within the subcutaneous tissue and no evidence of excessive pressure within the muscular compartments. Hemostasis was achieved. With dissection of this involved area of concern, the proximal aspect of the cephalic vein in the forearm and in the distal aspect of the basilic vein in the upper arm were both exposed. There was no soft tissue to be able to close over these. Given this fact, after hemostasis was assured and then it was clear that all infectious process had been debrided and wound cultures have been obtained, an Adaptic was placed to the wound bed and wound VAC then applied.
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The patient tolerated the procedure well. There were no complications. All counts were correct as reported to me at the end of the case.
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