Operation: Split thickness skin graft from right thigh to the right foot.

Indications: The patient is a 67-year-old male who suffered a full thickness burn to his right foot. The patient presents for split thickness skin graft.

Operative Description: The patient was taken to the operating room and placed supine on the operating table. The right lower extremity was prepped and draped in the standard sterile fashion.

Excisional debridement of the ulcer was carried out. The ulcer was approximately 4 × 5 cm in area in the lateral dorsum of the right foot. Debridement was carried down to viable skin tissue in order to prepare the site for the graft.

A 4 × 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 × 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.

Case Study 6

0HRMX74 Replacement, Skin, Foot, Right (0HRM)

0HBHXZZ Excision, Skin, Upper Leg, Right (0HBHXZ)

Rationale:

Skin for the skin graft is taken from the right thigh and then will be placed on the right foot.

Excisional debridement is performed to viable tissue to prepare the foot for the skin graft placement. It is not coded separately from the skin graft.

Coding Guideline B3.1b states, “Components of a procedure specified in the root operation definition or explanation as integral to that root operation are not coded separately. Procedural steps necessary to reach the operative site and close the operative site, including anastomosis of a tubular body part, are also not coded separately.”

Replacement Definition: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.

Example: Free Skin Grafts.

Alphabetic Index: Graft > See Supplement or Replacement. Free skin graft fit the definition of replacement (not supplement).

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