Skin laceration repair vs elbow repair
Hello,
I am looking for some guidance on when to use 0HQEXZZ (repair of left lower arm skin, external approach) versus 0XQCXZZ (repair of left elbow region, external approach). Here is an example of the procedure note below. Patient was admitted for acute renal failure and happened to fall during admission an had a laceration with was sutured at bedside. The repair of arm skin seems appropriate and end with medical DRG of 682, the repair of elbow results in a surgical DRG of 981, extensive OR procedure unrelated.
Is there any clarification I need to get from the provider or references to note in determining the most appropriate code? We have two differing views on this case.
"Laceration repair left elbow
Patient had a fall earlier this morning with
resultant hematoma of her head and left elbow laceration.
The laceration
was copiously irrigated with sterile normal saline and draped in sterile
fashion. The area surrounding the laceration was anesthetized with 1% lidocaine
with epinephrine. Once proper anesthesia was established 3 sutures were applied
to the Y-shaped laceration with 3-0 Prolene suture. The wound margins were well
approximated and no blood loss was noted during this procedure though she did
have quite a bit of bleeding immediately following the incident this morning
given that she is on Xarelto. The laceration was approximately 4mm X 4mm in size
in a Y shaped pattern.
She will likely need these sutures removed in
12-14 days. I did apply Neosporin to the wound with gauze and Coban following.
Will continue to monitor for signs of infection including erythema, drainage,
increased tenderness, swelling and fevers.
There were no complications to
this procedure today and she tolerated it well."
Thank you,
Janine Podany, MSN, RN
Comments
Thank you,
Janine