AUDIT REPORT T5.1 OPERATIVE REPORT, MUSCLE FLAP LOCATION: Inpatient, Hospital PA

Question

AUDIT REPORT T5.1 OPERATIVE REPORT, MUSCLE FLAP


LOCATION: Inpatient, Hospital
PATIENT: Jane Miller
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Right lower extremity open wound


POSTOPERATIVE DIAGNOSIS: Open wound, right lower extremity, with exposed
tibia and exposed plate


PROCEDURES PERFORMED: 1. Soleus muscle flap. 2. Split-thickness skin graft
3.0 × 3.0 cm from the right thigh to the right lower extremity.


ANESTHESIA: General endotracheal


ESTIMATED BLOOD LOSS: 60 cc


DRAINS: 1 no. 1 Jackson-Pratt


SURGICAL FINDINGS: There was an open wound extending from the lower third of
the tibia up into the middle third of the right leg with an exposed plate, but tissue loss
of the lower third of the right leg was evident.


PROCEDURE: An incision was made 3.0 cm medial to the tibial border. I developed
a bilobed flap and identified the separation of the soleus muscle and the gastrocnemius
medial head following incision of the deep fascia. The soleus muscle was freed
distally as far as possible and then cut distally at the Achilles tendon insertion. The
bilobed flap was formed covering the area of soft-tissue loss by using bolsters that
were tied in place with 0 Prolene. With the open area covered, I then closed the
remainder of the area, closing the donor area also with 0 Prolene. I put Nitro paste
along the edges where there was some skin blanching and put a no. 1 Jackson-Pratt
drain in the distal end of the wound, bringing it out through a separate stab wound
incision. A spit-thickness skin graft about 3.0 × 3.0 cm was taken from the right
thigh, meshed with a mesher, and applied to the defect with 2-0 Prolene, sutures, and
staples. We dressed the wound with Xeroform, Kerlix fluffs, Kerlix roll, Kling, and a
Sof-Rol, and then the orthopedic technician applied a cast. The donor site was dressed
with scarlet red and an ABD pad. The patient tolerated the procedure well and left the
area in good condition.


T5.1:
SERVICE CODE(S): 15738, 12032-51, 15100-RT__________________________
ICD-10-CM DX CODE(S): S81.809,Y93.9________________________________
ICD-9-CM DX CODE(S): 891.0, E030___________________________________
INCORRECT/MISSING CODE(S): _

Explanation / Answer

Inorrect code: S81.809

Correct: S81.801 A - Unspecified open wound of right lower leg, Initial encounter.

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