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Code This!

Scenario Week of May 04, 2012:
View Current Scenario

Preoperative Diagnosis: Multiple gunshot wounds with foreign bodies in the back and neck area.

Postoperative Diagnosis: Multiple gunshot wounds with foreign bodies in the back and neck area.

Operation:
1. Debridement of gunshot wound of the left deltoid
2. Removal of foreign body from the posterior neck
3. Removal of foreign body from the left upper back-parascapular – medial border of the scapula

Anesthesia: General

Complications: None

Blood Loss: Minimal

Drains: N/A

Indications:
This well-developed, well-nourished 19-year-old female was shot this evening in a drive-by shooting. According to police she was mistaken for a gang member. She was brought by ambulance to the emergency room where she was stabilized, then brought to the operating room for surgery to access and repair the damage and to remove the bullets or bullet fragments. A police officer was present throughout the surgery to gather evidence and for chain of custody.

Informed Consent:
The risks and benefits of the procedure were explained to the parent. The parent elected to proceed with the procedures.

Approach and Surgical Procedure:
The patient was placed supine on the operating table, and general anesthesia was induced. The patient was then placed in the right lateral decubitus position with the left side up. The patient was secured in position using beanbags. After that, cushions were applied to the axillary area and to the area beneath the knees and ankles. Next, the posterior neck, deltoid, and back were prepped and draped in the usual sterile fashion. Starting with the left deltoid gunshot wound, an elliptical incision was made around the wound, and devitalized tissue was debrided. The wound was extended to explore the wound and to determine if any foreign bodies were present. The subcutaneous cavity was also debrided, and hemostasis was achieved using electrocautery and clamps.

After achieving hemostasis, the cavity was packed with Betadine dressings, then sterile dressings were applied over the wound. Next, the patient was rotated to expose the upper neck and scapula area.

A transverse incision was made over the palpable foreign body in the upper-neck area. Using blunt and sharp dissection, this foreign body was removed from deep in the muscle tissue. It looked like a solid bullet with slight deformity. The bullet was brass colored and ovoid in configuration. After removing the bullet, the cavity was irrigated and hemostasis was achieved using electrocautery and clamp. Layered closure of the defect was accomplished and the skin was stapled closed. Then, using blunt and sharp dissection, access to a palpable mass in the parascapular soft tissue was obtained, and subsequently the mass was removed. This was another bullet apparently of the same color and shape as the previously mentioned foreign body. After removing the bullet, the cavity was irrigated, hemostasis was achieved, and the wound was closed with layered suture.

The skin was stapled closed, then sterile dressings were applied over the wound. At this point the procedures were completed, and the patient was transferred to the recovery room in stable condition having tolerated the procedures well.

Code this!


CPT Codes:
20103 Exploration of penetrating wound (separate procedure); extremity
20520-51-59 Removal of foreign body in muscle or tendon sheath; simple
23330-51-59 Removal of foreign body, shoulder; subcutaneous

CPT Rationale:
For the first procedure, debridement of gunshot wound of the left deltoid, look in the CPT index under the main term “exploration” where the subterms “extremity” and “penetrating wound” refer you to code 20103. When this code is referenced in the musculoskeletal section, it describes an exploration of a penetrating wound of the extremity. Therefore, this would be the appropriate code choice for the procedure performed.

Please note this code is a separate procedure, which is defined as a procedure or service commonly performed as an integral component of a total service or procedure. As such, this procedure should not be reported in addition to the code for a total procedure or service. However, when a procedure or service designated as a separate procedure is performed independently or is considered to be unrelated or distinct from other procedures or services provided at that time, it may be reported by itself. It may also be reported with other procedures or services. Append modifier 59 to the specific, separate procedure code to indicate that the service is not a component of another procedure; rather, it is a distinct, independent procedure representing a different session/patient encounter, procedure/surgery, site/organ system, incision/excision, lesion/injury or area of injury in extensive injuries.

For the second procedure, removal of foreign body from the posterior neck, look in the CPT index, under the term “removal.” It lists the subterm “foreign body” and then the anatomical location of “muscle.” The index refers you to the code range 20520-20525. When this code range is referenced in the musculoskeletal section, it describes a removal of foreign body in the muscle or tendon sheath. CPT code selection is dependent on whether the removal is simple or deep/complicated.

When a simple foreign body is removed (CPT code 20520), the physician incises the skin and dissects to the muscle or sheath. A deep or complicated foreign body removal (CPT code 20525) would indicate a very deep removal, an infected wound, or a complicated removal.

In this procedure, a simple foreign body was removed from the muscle. It would be appropriate to report CPT code 20520.

For the third procedure, removal of foreign body from the left upper back-parascapular – medial border of the scapula, look in the CPT index under the term “removal” where the subterms “foreign body” and then the anatomical location of “shoulder” and “subcutaneous”are listed which reference code 23330. In this procedure a simple foreign body was removed from the subcutaneous tissue, so it would be appropriate to report CPT code 23330.

Modifier 51 is appended to the second and third procedures to indicate that they were multiple procedures. Modifier 59 is reported on the second and third procedures in this instance to indicate that the foreign body removals are from sites other than the wound exploration site.

ICD-9-CM Diagnosis Codes:
880.03 Open wound of shoulder and upper arm, upper arm, without mention of complication
880.11 Open wound of shoulder and upper arm, scapular region, complicated
874.9 Open wound of other and unspecified parts of neck, complicated
E965.4 Assault by other and unspecified firearm

ICD-9-CM Rationale:
For the wounds of the deltoid and parascapular – medial border of the scapula area, the correct codes are found in ICD-9-CM index under the main term “wound, open” and the subterm “shoulder” which references code 880.00.

Because the wound to the deltoid is not stated to contain a foreign body, it is appropriate to report ICD-9-CM code 880.0 "without mention of complication.” This code also requires a fifth-digit classification to identify the specific area of the wound, which in this case would be “3” for upper arm. The wound of the scapular region was found to contain a foreign body, and is considered a complicated wound. In this case, code 880.1 with the fifth digit of “1” to identify the scapular region should be reported.

These two wounds, although they are close in proximity, would not be classified to the same fourth-digit subcategory because the fourth digits distinguish the status of the wound as complicated, uncomplicated, and with tendon involvement. As they are not the same for both wounds, it is necessary to report each wound separately.

For the neck wound, the correct code is found in the ICD-9-CM index under the main term “wound, open” and the subterms “neck” and “complicated” which reference code 874.9.

When category 874 is referenced in the tabular listing of ICD-9-CM, there are several codes for open wound of neck. Like the shoulder wound, this wound is also considered to be complicated due to the presence of the foreign body. Since the specific area of the neck in this case, the posterior, is not specifically identified by codes in this category, code 874.9 Open wound of other and unspecified parts of neck, complicated, is reported.

Next a code is assigned for the circumstance that caused the injury, which is described by E codes. For this code, look in the ICD-9-CM external causes alphabetic index, section 3, under the main term “shooting” and the subterm “inflicted by other person,” then “intentional, homicidal” which references code E965.4.

When category E965.4 is referenced in the tabular listing of ICD-9-CM, it describes an assault by other and unspecified firearm. This code would be the appropriate code to use for the drive-by shooting.

For this scenario, it is not necessary to report a V status code for the foreign bodies. These codes would only be reported for retained (old), embedded foreign bodies with the potential to cause infection or other problem. Since "complicated" in the acute diagnosis code (fourth digit 1) accounts for the foreign bodies, which were removed, there is no "retained" status.

 
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