Patient Coding Scenario ICD 10

Patient Name: Vera Johnson DOB: 08-08-63 Sex: F Date of Service: 09-18-XX Surgeon: Daniel Manning, MD

Pre-Operative Diagnosis: Non-Healing Wound, left foot

Post-Operative DiagnosisNon-healing DM1 ulcer with peripheral neuropathy left foot, Charcot foot unrelated to DM1

Procedure Performed: Left BKA (mid)Anesthesia: GeneralComplications: NoneIndications for Procedure:This patient presents with a history of a Charcot foot (joint disease) with a nonhealing wound on the lateral aspect and heel of the left foot with bone necrosis. She is being brought for a left below-knee amputation. We discussed the patient risks, benefits, and alternatives. She agrees to proceed.

Description of Procedure:

After informed consent was obtained, the patient was brought to the operative room, placed in supine position. After anesthesia was induced, she was prepped and draped in a standard sterile manner. After a time-out was performed, incision was made along the anterior aspect of the leg and deepened down through subcutaneous tissues. We fashioned a flap posteriorly along the gastrocnemius and cutaneous tissues. Subsequently, we dissected down identifying multiple small veins, these were ligated using silk ties. We incised the fascia using Bovie electrocautery. Subsequently, we divided the muscles of the anterior compartment, identified the anterior tibial structures and these were divided using silk ties. Subsequently, we dissected around the fibula. We subsequently transected the tibia using a bone saw. Once again, this transected the fibula using a bone saw. We completed our posterior flap using an amputation knife and subsequently obtained hemostasis using 3-0 silk suture ligatures and 3-0 silk ties as well as Bovie electrocautery. Once we obtained adequate hemostasis, we then trimmed the tibia and the fibula once again to allow for good angling of the tibia as well as for adequate length on the fibula which was even with the level of the tibia. At this point, we then irrigated with copious amounts of antibiotic saline and then the wound was closed reapproximating the posterior to the anterior fascia using 2-0 PDS sutures in an interrupted fashion and a 3-0 PDS was used in a deep dermal fashion for skin closure as well as 3-0 nylon sutures and staples for final skin closure. Sterile dressings were applied. The patient tolerated the entire procedure well and was transferred to the recovery area in stable condition. I, Dr. Daniel Manning, was present and performed her entire procedure up until final skin closure. All sponge, instrument, and needle counts were correct.

Electronically Signed By: Daniel Manning, MD

ANSWER THE FOLLOWING:

First Listed/Principal DX:______________________

Secondary (additional) Diagnosis Code(s):

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4.

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