The patient is a 33 year old male steelworker who suffered a full thickness burn two months ago from molten iron splashing onto his right foot. He also has pure hypercholesterolemia and hypertension. There is a 40 pack a year smoking history but the patent did quit 10 years ago. The patient presents for elective debridement of the healing wound and split thickness skin graft. OPERATION: Split thickness skin graft from right thigh to right foot. OPERATIVE REPORT: The patient was taken to the operating room and placed supine on the operating table. After adequate IV sedation was provided, the right lower extremity was prepped and draped in the standard sterile fashion. Sharp debridement of the ulcer was carried out. The ulcer was approximately 4 x 5 cm in area in the lateral dorsum of the right foot. Debridement was carried down to viable tissue. A 4 x 5 cm split thickness skin graft was harvested from the upper aspect of the right thigh. The graft was then meshed and applied to the right foot wound. The graft was secured with a running locked #3-0 chromic suture. Two centrally located chromic sutures were placed for further support. Attention was placed to the donor site, which was dressed with Xeroform and 4 x 4 gauze. The right lower extremity was then wrapped in Kerlix dressing. Sponge and instrument counts were correct at the end of the case. The patient tolerated the procedure well and was transported to the recovery room. Code the following: 1 point – Admitting Diagnosis: (1 code) (No POA modifier) 2 points – Principal Diagnosis: (1 code) (include POA modifier) 8 points – Secondary Diagnoses: (4 codes) (include POA modifiers) 1 point – Principal Procedure: (1 code) (CPT code) 1 points – Secondary Procedures: (1 code) (CPT code)
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