PREOPERATIVE DIAGNOSIS: Decubitus ulcer, stage IV, left hip.POSTOPERATIVE DIAGNOSIS: Decubitus ulcer, stage IV, left hip.OPERATION PERFORMED: Excision of stage IV decubitus ulcer, left hip. The patient is a 30-year-old autistic male who also has multiple sclerosis. The patient is bed-bound and totally nonambulatory at this point, and he has developed a decubitus ulcer of the left hip. The patient was brought to the operating suite, and after administration of a regional block, the patient was prepped and draped in a sterile fashion. The area of the ulcer over the patient's left hip was probed and examined. The ulcer had moved down through the fascia and muscle level to the greater trochanteric process. The size of the ulcer was 6.0 x 7.0 x 8.0 cm. The ulcer was removed, and the defect created from this excision required a myocutaneous flap. This was done after a section of the trochanteric process was removed. The area was bandaged. The patient was in stable condition when he was moved to the recovery room. Assign the correct diagnosis, procedure code(s) and applicable modifier(s) for this encounter.
PREOPERATIVE DIAGNOSIS: Decubitus ulcer, stage IV, left hip.POSTOPERATIVE DIAGNOSIS: Decubitus ulcer, stage IV, left hip.OPERATION PERFORMED: Excision of stage IV decubitus ulcer, left hip. The patient is a 30-year-old autistic male who also has multiple sclerosis. The patient is bed-bound and totally nonambulatory at this point, and he has developed a decubitus ulcer of the left hip. The patient was brought to the operating suite, and after administration of a regional block, the patient was prepped and draped in a sterile fashion. The area of the ulcer over the patient's left hip was probed and examined. The ulcer had moved down through the fascia and muscle level to the greater trochanteric process. The size of the ulcer was 6.0 x 7.0 x 8.0 cm. The ulcer was removed, and the defect created from this excision required a myocutaneous flap. This was done after a section of the trochanteric process was removed. The area was bandaged. The patient was in stable condition when he was moved to the recovery room.
Assign the correct diagnosis, procedure code(s) and applicable modifier(s) for this encounter.
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