Provide information about the CPT and ICD-9-CM diagnosis codes for the following scenario.
INDICATIONS: The patient had a YV advancement flap and advancement of the hamstring muscles about 3 weeks ago, but the wound separated and the muscles retracted over the area of the bone. She has had moderate separation of the wound but not complete separation, and we plan to minimally debride this area and resuture the wound with tension sutures.
DIAGNOSIS: Wound dehiscence, left ischial area, partial.
SURGICAL FINDINGS: A 6 cm long by about 4 cm deep wound dehiscence.
PROCEDURE PERFORMED: Debridement of ischial wound by curettage with secondary wound closure.
RELEVANT CODING DETAILS OF PROCEDURE:
Betadine scrub and sterile drape.
Tissue culture tubed to granulation tissue.
Debridement of granulation.
Far/near near/far tension type sutures using #2 Ethibond.
Xeroform underneath sutures.
Three boxes of Kerlix Fluffs.
Taped with Elastoplast.
ABD pad over the open areas.
Elastoplast to support the ischial area.
Home health care nurse advised as to how to retape and dress.
Scarlet Red and ABD pads to donor site and to old skin graft site.
Estimated blood loss 50 cc.
What is the CPT Code?
What is the ICD-9-CM Code?
The CPT and the ICD code sets are developed by national and international organizations and are used for uniform medical information about billing, procedures and medical services for the benefit of doctors, billing departments (coders), patients and payers. This uniform coding (designation of identifying alpha-numerical codes) aids in fulfilling administrative and financial purposes.
The CPT is the Current Procedural Terminology code set and is maintained by the American Medical Association. The CPT is the coding system mandated by the Centers for Medicare and Medicaid Services and by HIPAA. It describes medical, surgical, and diagnostic services so as to have uniform information throughout the applicable system.
Since the above situation involved surgical procedures, the CPT code category would be Category I, Codes for surgery: 10000–69990, specifically the subdivision of codes for the musculoskeletal system: 20000–29999. Since instruction was given to a home helath care nurse, Codes for medicine: 90281–99099; 99151–99199; 99500–99607, would also apply for home health procedures/services: 99500–99602.
The ICD codes and its several variations were developed out of international conferences convened by the World health Organization, or WHO. The International Classification of Diseases (ICD) is used internationally and by the United States where its use is overseen by the U.S. NCHS and the Centers for Medicare and Medicaid Services.
Modifications were made to the basic ICD in 1975 at the International Conference for the Ninth Revision of the International Classification of Diseases, convened in Geneva by WHO. The international community uses the ICD-9 while the U.S. uses a variation ICD-9-CM (CM: Clinical Modification) applicable to U.S. needs.
Volume 1 of the ICD-9-CM contains diagnostic codes (Volume 2 is an index to Volume 1) and Volume 3 contains procedure codes.
Since the injury was a deep muscle wound, CHAPTER 13 - Diseases of the musculoskeletal system and connective tissue (M00-M99) of the ICD-9-CM would apply. Since there were skin graft sites, CHAPTER 12 - Diseases of the skin and subcutaneous tissue (L00-L99) would apply