So this is a new one for me. We had a patient come in immediately following an amputation of his thumb by a power tool. The amputation was complete and my physician sutured the skin together to "close the amputation site." Patient did not want his amputated part re-attached. Thoughts on how to properly bill the work my physician did?

HPI:
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Patient is a 62 year old male here after cutting off part of thumb.
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Left thumb amputation
– was cutting fire wood this morning with large axe
– leg bumped the handle and it chopped his left thumb off
– finished feeding the animals
– found thumb in snow, put it in bag with ice
– lives an hour out of town in Imnaha
– put some towels on it
– can still feel everything and move thumb around
– does sculpt, make handmade saddles
– right handed
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Review of Systems
Constitutional: Negative for chills and fever.
Neurological: Negative for dizziness and tingling.
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Patient Active Problem List
Diagnosis
• Ankylosing spondylitis of multiple sites in spine (HCC-CMS)
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Current Outpatient Prescriptions
Medication Sig Dispense Refill
• cephalexin (KEFLEX) 500 mg capsule Take 1 Cap by mouth 4 (four) times daily for 5 days 20 Cap 0
• oxyCODONE-acetaminophen (PERCOCET) 5-325 mg per tablet Take 1 Tab by mouth every 8 (eight) hours as needed for pain 15 Tab 0
• prednisoLONE acetate (PRED FORTE) 1 % ophthalmic suspension Place 1 Drop into the right eye 4 (four) times daily 10 mL 2
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Current Facility-Administered Medications
Medication Dose Route Frequency Provider Last Rate Last Dose
• cefTRIAXone 1 g injection 1 g intramuscular Once Katie Putnam, MD

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Objective

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Vitals
Vitals:
* 02/19/19 0820
Pulse: 76
SpO2: 95%
Weight: 202 lb (91.6 kg)
Height: 6′ (1.829 m)

Last 3 Vitals
Office Visit from 2/19/2019
Temp — 97.7 °F (36.5 °C) 98 °F (36.7 °C)
Pulse 76 75 56
BP — — 147/76
Resp — 16 14
Weight 202 lb (91.6 kg) 196 lb (88.9 kg) 189 lb (85.7 kg)
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Estimated body mass index is 27.4 kg/m² as calculated from the following:
Height as of this encounter: 6′ (1.829 m).
Weight as of this encounter: 202 lb (91.6 kg).
Facility age limit for growth percentiles is 20 years.
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Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.
Talking, making jokes.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Conjunctivae and EOM are normal.
Neck: Neck supple.
Cardiovascular: Intact distal pulses.
Pulmonary/Chest: Effort normal.
Musculoskeletal: Normal range of motion.
L thumb: Traumatic amputation distal of IP joint. Extensor and flexor mechanisms in tact. Approximately 10% of the base of the thumb nail present. There is a small, arterial bleed near the palmar aspect of the thumb. Bone present underneath macerated tissue, some oozing from bone. Sensation appears to be in tact.
Neurological: He is alert and oriented to person, place, and time.
Skin: Skin is warm and dry.
Psychiatric: He has a normal mood and affect. His behavior is normal. Judgment and thought content normal.

Procedure: amputation repair / partial closure:
Anesthesia with 6 mL of 1% Lidocaine without Epinephrine used for digital block of L thumb. Wound cleansed, upon examination the wound probed to bone. 6-0 vicryl was used to place a single figure-of-eight suture at the site of a small arterial bleed, good hemostasis was achieved. There was continued oozing from the bone, so 4-0 vicryl and 3-0 ethilon were used to gently reapproximate the overlying skin; good hemostasis was achieved. Antibiotic ointment, xeroform dressing and gauze was used and the wound was wrapped with overlying coban. Wound care instructions provided. Single ceftriaxone shot was administered. Observe for any signs of infection or other problems. Return for wound examination in 1 day. Return for suture removal in 7 days.

Assessment and Plan: Patient is a 62 year old male here for finger amputation.
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1. Traumatic amputation of left thumb, initial encounter
2. Contact with workbench tool, initial encounter
3. Need for diphtheria-tetanus-pertussis (Tdap) vaccine
Traumatic amputation of the left thumb due to axe injury. Flexor and extensor function in tact. Wound cleansed and repair with gentle reapproximation of tissue as above. Discussed with orthopedic team in ***who stated that replant was a possible option but may be unsuccessful given time of injury. Patient declined to go to *** for evaluation. Good hemostasis was achieved with the repair, wound dressed with plan for check-up tomorrow. Recommending that patient be seen by orthopedic team in *** this week or next week; patient reluctant given concerns about transportation in winter weather. Will emphasize this recommendation again tomorrow. CTX and TDAP given today. Small rx for oxycodone-acetaminophen given as patient unable to take NSAIDs.
– IMMUNIZATION ADMIN
– TDAP (7 + YEARS)
– INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG
– cephalexin (KEFLEX) 500 mg capsule; Take 1 Cap by mouth 4 (four) times daily for 5 days Dispense: 20 Cap; Refill: 0
– cefTRIAXone 1 g injection; Inject 1 g into the muscle once