ICD-10-PCS 2. Operative Report HISTORY: This 83-year-old white female patient wi
ID: 245368 • Letter: I
Question
ICD-10-PCS
2. Operative Report
HISTORY: This 83-year-old white female patient with diabetes was admitted with gangrenous discoloration and purulent drainage from the right third toe.
PROCEDURE DESCRIPTION: The patient was taken to the operating room, monitored and sedated per anesthesia. 35 cc of 0.25% Marcaine plain was infiltrated into the skin and subcutaneous tissues over the forefoot and ankle, and at the base of third toe for a regional block anesthesia. The foot was prepped and draped in a sterile fashion.
An elliptical incision at the base of the toe was then made with a scalpel. The incision was extended through the subcutaneous tissue. The anterior and posterior tendons were divided. The joint was disarticulated. The toe was completely removed and sent as a surgical specimen. The wound was irrigated with copious amounts of saline. The subcutaneous tissue and tendinous tissue was then approximated over the bone using interrupted sutures of 2-0 Vicryl and the skin was closed with interrupted mattress sutures of 3-0 Prolene. A sterile dressing was applied.
The patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: 5 cc
Root Operation: (Index Main Term)
Body Part: (Index Sub-Term)
Approach:
Device:
Qualifier:
Final Code(s):
PREOPERATIVE DIAGNOSIS: Diabetic foot infection, gangrenous right third toe POSTOPERATIVE DIAGNOSIS: Diabetic foot infection, gangrenous right third toe PROCEDURE: Right third toe amputationExplanation / Answer
Root operation: toe amputation- Z89.429
Body part: right third toe - T
Approach: Open - 0
Device: no device - Z
Qualifier: complete- 0