Post-traumatic arthritis
I have a pt. that the surgeon states posttraumatic arthritis of LT knee; complication of orthopedic implant, LT tibia; Hx of LT tibial plateau fracture from 25yrs ago. The pt. has previously had LT knee hardware mostly removed except for 1 screw which he has just now got removed. They were going to do a TKR but he had absence of subcu fat & skin was dusky in appearance so he underwent a muscle flap & skin graft to the knee to reduce the risk of wound breakdown & infection. He will obtain a TKR after he heals from the grafts.
Can someone help me with this. The surgeon didn't say what the complication was. Since pt. no longer has the hardware/implant, do I still code as unspecified complication of implant and do I code the fracture w/last digit of S since it happened 25 yrs ago? Pt. will receive PT and nurse has requested wound care orders. If nurse gets wound care orders, do I code SX aftercare of skin for the skin graft?
Can someone help me with this. The surgeon didn't say what the complication was. Since pt. no longer has the hardware/implant, do I still code as unspecified complication of implant and do I code the fracture w/last digit of S since it happened 25 yrs ago? Pt. will receive PT and nurse has requested wound care orders. If nurse gets wound care orders, do I code SX aftercare of skin for the skin graft?