PATIENT WORKSHEET 1.1: SUPERFICIAL SSI

PATIENT WORKSHEET 1.1: SUPERFICIAL SSI
Scenario: A 32-year-old woman presented with chronic abdominal pain. She was previously found to have pelvic floor dysfunction. Pelvic floor retraining was tried with out success. Hand assisted laparoscopic subtotal colectomy with ileorectostomy was performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination Oral Antibiotics For 2 weeks Post Op Hospital Length of stay (days) 5 1 – 10 days Fever Erythema Induration Pain IV antibiotics SUPER-FICIAL INCISIONALSSI Tests 1, CBC IV antibiotics + Wound vacuum Discharge to Home Out patient follow up IV antibiotics + Wound opening + Wound packing Repeat WBC count 24 – 48 hours Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Complete Blood Count (85027) once a day for 4days Blood Draw (36415) Oral Antibiotics: One of the following is prescribed for days; Cephalexin cap; Levofloxacin tab Augmentin Tab. CBC (CPT 85027) $13.08 Total Cost Blood Draw (CPT 36415) $ Total Cost Oral Antibiotics Cephalexin cap $54 Total Cost Levofloxacin tab $111 Total Cost Augmentin tab $ Total Cost Cost Range = $ to $432.76

Scenario: A 62-year-old woman with iron deficiency anemia underwent colonoscopy which showed a large polyp not amenable to removal. Biopsy showed fragments of tubulovillous adenoma and low grade dysplasia. Laparoscopic assisted right hemicolectomy was performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination Oral Antibiotics For 2 weeks Post Op Hospital Length of stay (days) 5 1 – 10 days Fever Erythema Induration Pain IV antibiotics SUPER-FICIAL INCISIONALSSI Tests 1, WBC IV antibiotics + Wound vacuum Discharge to Home Out patient follow up IV antibiotics + Wound opening + Wound packing Repeat WBC count 24 – 48 hours Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Complete Blood Count (85027) once a day for 4days Blood Draw (36415) IV antibiotics: One of the following is prescribed for 4 days: Levofloxacin IV; Cefazolin IV. Oral Antibiotics: One of the following is prescribed for days; Cephalexin cap; Levofloxacin tab Augmentin Tab. CBC (CPT 85027) $13.08 Total Cost Blood Draw (CPT 36415) $ Total Cost IV Antibiotics Levofloxacin IV $67.64 Total Cost Cefazolin IV $ Total Cost Oral Antibiotics Cephalexin cap $54 Total Cost Levofloxacin tab $111 Total Cost Augmentin tab $ Total Cost Cost Range = $ to $483.32

Scenario: A 56-year-old woman with ten year history of Crohn's disease presented with abdominal discomfort, bloating, nausea and vomiting. She was on Remicade and 6-mercaptopurine with no relief of symptoms. CT abdomen showed evidence of stricturing Crohn's disease. Hand assisted laparoscopic small bowel resection with stricturoplasties were performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination Oral Antibiotics For 2 weeks Post Op Hospital Length of stay (days) 5 1 – 10 days Fever Erythema Induration Pain IV antibiotics SUPER-FICIAL INCISIONALSSI Tests 1, CBC IV antibiotics + Wound vacuum Discharge to Home Out patient follow up Repeat CBC count 24 – 48 hours Daily Wound Dressing Visiting Nurse Home visits + Wound dressing / Home Wound Vac IV antibiotics + Wound opening + Wound packing Complete Blood Count (85027) once a day for 4days Blood Draw (36415) IV antibiotics: One of the following is prescribed for 4 days: Levofloxacin IV; Cefazolin IV. Wound vacuum X 4 days (Assuming patient required Wound Vacuum only in hospital) - There is no billing event for daily wound dressing – Nursing time. Oral Antibiotics: One of the following is prescribed for 10 days; Cephalexin cap; Levofloxacin tab Augmentin Tab. CBC (CPT 85027) $13.08 Total Cost Blood Draw (CPT 36415) $ Total Cost IV Antibiotics Levofloxacin IV $67.64 Total Cost Cefazolin IV $ Total Cost Wound Vacuum $300 Total Cost Daily wound dressing: not billed Oral Antibiotics Cephalexin cap $54 Total Cost Levofloxacin tab $111 Total Cost Augmentin tab $ Total Cost Cost Range = $1, to $1,683.32

A 56 year old female presented with low pelvic pain and urinary tract symptoms. CT abdomen and pelvis revealed an abscess in the pouch of Douglas with fistula from the abscess to the sigmoid colon, due to diverticulitis. Abdominal exploration with drainage of pelvic abscess and sigmoid resection was performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination Oral Antibiotics For 2 weeks Post Op Hospital Length of stay (days) 5 1 – 10 days Fever Erythema Induration Pain IV antibiotics SUPER-FICIAL INCISIONALSSI Tests 1, WBC IV antibiotics + Wound vacuum Discharge to Home Out patient follow up IV antibiotics + Wound opening + Wound packing Repeat WBC count 24 – 48 hours Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Complete Blood Count (85027) once a day for 4days Blood Draw (36415) IV antibiotics: One of the following is prescribed for 4 days: Levofloxacin IV; Cefazolin IV. There is no billing event for daily wound dressing – Nursing time. Oral Antibiotics: One of the following is prescribed for 10 days; Cephalexin cap; Levofloxacin tab Augmentin Tab. CBC (CPT 85027) $13.08 Total Cost Blood Draw (CPT 36415) $ Total Cost IV Antibiotics Levofloxacin IV $67.64 Total Cost Cefazolin IV $ Total Cost Wound opening and packing: not billed when done on the floors Oral Antibiotics Cephalexin cap $54 Total Cost Levofloxacin tab $111 Total Cost Augmentin tab $ Total Cost Cost Range = $ to $483.32

PATIENT WORKSHEET 2.1: DEEP INCISIONAL SSI
Scenario: A 35-year-old male with medically refractory crohns disease presented with small bowel obstruction. He had h/o multiple hospitalizations and small bowel obstruction and multiple stricturoplasties. He is currently on high dose steroids and 6-mercaptopurine. Exploratory laparotomy, resection of ileocolic anastomosis and stricturoplasty were performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination IV Antibiotics + Wound opening + Wound packing Post Op Hospital Length of stay (days) 9 Fever Erythema Induration Pain Discharege Daily Wound Dressing Oral Antibiotics / 2 weeks DEEP INCISIONALSSI IV antibiotics + Wound opening + Wound vacuum Discharge to Home Out patient follow up Tests 1, CBC 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Repeat WBC count 24 – 48 hours IV antibiotics + Wound debridement in Operative room CT Scan Abdomen w/ contrast (74160) CT Scan Pelvis w/ contrast (72193) IV antibiotics: One of the following is prescribed X 8 days (changed to oral antibiotics once the patient feels better): Levofloxacin IV; Cefazolin IV. There is no billing event reported for daily wound dressing. (also for wound opening and packing on the floors) Oral Antibiotics: 7 days 1. Cephalexin cap; 2. Levofloxacin tab; 3. Augmentin Tab. Room Costs (Not billed with CPT4 codes) X 4 days extra stay for Deep Incisional SSI. Complete Blood Count (85027) once a day X 8 days Blood Draw (36415) General Bacterial Culture (87086) Grams Stain (87025) Antibiotic susceptibility (87186) CBC (CPT 85027) $26.16 Total Cost Blood Draw (CPT 36415) $ Total Cost General Bacterial Culture (CPT 87070) $27.83 Total Cost Grams Stain (CPT 87205) $22.10 Total Cost Antibiotic susceptibility (CPT 87186) $29.78 Total Cost CT Scan Abdomen w/contrast (CPT 74160) $ Total Cost CT Scan Pelvis w/contrast (CPT $ Total Cost IV Antibiotics Levofloxacin IV $135.28Total Cost Cefazolin IV $ Total Cost Oral Antibiotics Cephalexin cap $37.80 Total Cost Levofloxacin tab $77.70 Total Cost Augmentin tab $ Total Cost Daily wound dressing: not billed Semiprivate Room $3, Total Cost Private Room $3, Total Cost Cost Range = $4, to $5,603.90

Scenario: A 50-year-old male presented for elective resection of the sigmoid colon after two document episodes of diverticulitis. One of the episode required hospitalization with IV antibiotics. Colonoscopy did not reveal any other pathology except for edematous sigmoid colon. CT abdomen & pelvis showed marked thickening of the sigmoid colon and inflammatory stranding in the pericolonic fat. Laparoscopic converted to open, sigmoid Colectomy was performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination IV Antibiotics + Wound opening + Wound packing Post Op Hospital Length of stay (days) 9 Fever Erythema Induration Pain Discharege Daily Wound Dressing Oral Antibiotics / 2 weeks DEEP INCISIONALSSI IV antibiotics + Wound opening + Wound vacuum Discharge to Home Out patient follow up Tests 1, WBC Count 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Repeat WBC count 24 – 48 hours IV antibiotics + Wound debridement in Operative room CT Scan Abdomen w/ contrast (74160) CT Scan Pelvis w/ contrast (72193) IV antibiotics: One of the following is prescribed X 8 days (changed to oral antibiotics once the patient feels better): Levofloxacin IV; Cefazolin IV. There is no billing event reported for daily wound dressing Oral Antibiotics: 7 days 1. Cephalexin cap; 2. Levofloxacin tab; 3. Augmentin Tab. Room Costs (Not billed with CPT4 codes) X 4 days extra stay for Deep Incisional SSI. Complete Blood Count (85027) once a day X 8 days Blood Draw (36415) General Bacterial Culture (87086) Grams Stain (87025) Antibiotic susceptibility (87186) CBC (CPT 85027) $26.16 Total Cost Blood Draw (CPT 36415) $ Total Cost General Bacterial Culture (CPT 87070) $27.83 Total Cost Grams Stain (CPT 87205) $22.10 Total Cost Antibiotic susceptibility (CPT 87186) $29.78 Total Cost CT Scan Abdomen w/contrast (CPT 74160) $ Total Cost CT Scan Pelvis w/contrast (CPT $ Total Cost IV Antibiotics Levofloxacin IV $135.28Total Cost Cefazolin IV $ Total Cost Oral Antibiotics Cephalexin cap $37.80 Total Cost Levofloxacin tab $77.70 Total Cost Augmentin tab $ Total Cost Wound Vacuum $2,400 Total Cost Daily wound dressing: not billed Semiprivate Room $3, Total Cost Private Room $3, Total Cost Cost Range = $7, to $8,003.90

Scenario: A 57-year-old male comes with h/o right upper quadrant abdominal pain for 5 months accompanied with decreased appetite and weight loss. Colonoscopy showed an annular lesion in the ascending colon which is biopsy proven adenocarcinoma. The metastatic work up was negative. Laparoscopic Right hemicolectomy was performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination IV Antibiotics + Wound opening + Wound packing Post Op Hospital Length of stay (days) 9 Fever Erythema Induration Pain Discharege Daily Wound Dressing Oral Antibiotics / 2 weeks DEEP INCISIONALSSI IV antibiotics + Wound opening + Wound vacuum Discharge to Home Out patient follow up Tests 1, WBC Count 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. Visiting Nurse Home visits + Wound dressing / Home Wound Vac Daily Wound Dressing Repeat WBC count 24 – 48 hours IV antibiotics + Wound debridement in Operative room CT Scan Abdomen w/ contrast (74160) CT Scan Pelvis w/ contrast (72193) IV antibiotics: One of the following is prescribed X 8 days (changed to oral antibiotics once the patient feels better): Levofloxacin IV; Cefazolin IV. Wound debridement in the operative room is not coded with CPT Codes Oral Antibiotics: 7 days 1. Cephalexin cap; 2. Levofloxacin tab; 3. Augmentin Tab. Room Costs (Not billed with CPT4 codes) X 4 days extra stay for Deep Incisional SSI. Complete Blood Count (85027) once a day X 8 days Blood Draw (36415) General Bacterial Culture (87086) Grams Stain (87025) Antibiotic susceptibility (87186) CBC (CPT 85027) $26.16 Total Cost Blood Draw (CPT 36415) $ Total Cost General Bacterial Culture (CPT 87070) $27.83 Total Cost Grams Stain (CPT 87205) $22.10 Total Cost Antibiotic susceptibility (CPT 87186) $29.78 Total Cost CT Scan Abdomen w/contrast (CPT 74160) $ Total Cost CT Scan Pelvis w/contrast (CPT $ Total Cost IV Antibiotics Levofloxacin IV $135.28Total Cost Cefazolin IV $ Total Cost OR Cost $____ Total Cost PACU Cost (IP 10230) $ Total Cost AlloDerm graft (IP ) $4,300 Total Cost Spinal Anesthesia (IP 21885) $1, Total Cost Anesthesia supplies $ Total Cost Oral Antibiotics Cephalexin cap $37.80 Total Cost Levofloxacin tab $77.70 Total Cost Augmentin tab $ Total Cost Semiprivate Room $3, Total Cost Private Room $3, Total Cost Cost Range = $7, to $12,624.43 + Procedure Costs

PATIENT WORKSHEET 3.1: ORGAN/SPACE SSI
Scenario: A 75 year old gentleman presented with recent changes in his bowel habits including bleeding per rectum and was recommended a screening colonoscopy. Colonoscopy showed pan diverticulosis and ulcerative lesion 10 cm from the anal verge. Biopsy proved it to be an high grade dysplasia. He had h/o prostate cancer. Prostectomy was performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination IV Antibiotics Conservative management Post Op Hospital Length of stay (days) 11 Fever Erythema Induration Pain Discharege ICU Care Incubation for 24 – 48 hours with multiple CXR, ABG, WBC, Electrolytes, Creatinine, etc. Repeat CT every 5-7 days Out patient follow up ORGAN / SPACE SSI IV antibiotics + CT guided Drainage Floor Care Tests 1, WBC Count 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. Blood Culture 6. Chest X-Ray 7. URINE Analysis 2 week IV antibiotics 2 week Oral antibiotics Visiting Nurse Home visits + Wound dressing / Home Wound Vac Repeat WBC count 24 – 48 hours IV antibiotics + Operative room Drainage Assuming Organ/Space SSI was diagnosed in POD#1 which leaves 10 days of hospital stay: CPT4 codes are reported in parenthesis; Complete Blood Count (85027) one-two times a day X 10 days (including ICU); CT Scan Abdomen w/ contrast (74160) X 1; CT Scan Pelvis w/ contrast (72193) X 1; Blood Draw (36415) X many times; Blood Culture (87040) X 1; Grams Stain (87025) X 1; Antibiotic susceptibility (87186) X 1; Chest X-ray PA & lateral (71020) ; X-ray Abdomen (74000); Urinalysis, routine (81001). IV antibiotics: One of the following is prescribed X 10 days (changed to oral antibiotics once the patient feels better): Piperacillin/ Tazobactam IV; Vancomycin IV; Levofloxacin IV; Cefazolin IV; (+/-) Metronidazole IV. Oral Antibiotics: Either one of the following is prescribed X 10 days (Assuming IV antibiotics are changed into oral antibiotics on the day of discharge): 1. Cephalexin cap; 2. Levofloxacin tab; 3. Augmentin Tab. ICU care for hours (Assuming 48 hours in ICU will have the following investigations and care): ICU room cost (not billed with any CPT Codes); Complete Blood Count X 4 times (85027) ; Chest x-ray portable (71010) X 2; Arterial Blood Gases X 2 (82805); Sodium X 2 (84295); Potassium X 2 (84132); Chlorides X 2 (82435); Phosphorus X 2 (84100); Magnesium X 2 (83735); Blood urea Nitrogen X 2 (84520); Creatinine X 2 (82565); Glucose X 2 (82948); Ionized calcium X 2 (82330); Prothrombin Time X 2 (85610); Activated partial thromboplastin time X 2 (85730); Electro Cardiogram X 1 (93000); Complete Parenteral Nutrition: Adult (CPT Code – not listed); Repeat CT Scan Abdomen w/ Contrast (74160) X 1; Repeat CT scan Pelvis w/ contrast (72193) X 1. Floor Care: Room costs (not billed with any CPT Codes) X 4 days extra stay for SSI. CBC (CPT 85027) $26.16 Total Cost/$32.70 no ICU Blood Draw (CPT 36415) $ Total Cost/ no ICU CT Scan Abdomen w/contrast (CPT 74160) $ Total Cost CT Scan Pelvis w/contrast (CPT $ Total Cost General Bacterial Culture (CPT 87070) $27.83 Total Cost Grams Stain (CPT 87205) $22.10 Total Cost Antibiotic susceptibility (CPT 87186) $29.78 Total Cost Chest X-Ray & lateral (CPT 71020) $52.89 Total Cost X-Ray Abdomen (CPT 74000) $66.03 Total Cost Urinalysis, routine (CPT 81001) $21.21 Total Cost IV Antibiotics Levofloxacin IV $135.28Total Cost Cefazolin IV $ Total Cost Piperacillin/Tazobactam IV $1, Total Cost Metronidazole Premix $ Total Cost Vancomycin IV $ Total Cost ICU Room Cost $5,335,74 Total Cost Other ICU Care (18 other tests) $1,253.70 Oral Antibiotics Cephalexin cap $37.80 Total Cost Levofloxacin tab $77.70 Total Cost Augmentin tab $ Total Cost Metronidazole tab $38.22 Total Cost Min. is no ICU adm. & no CPN; levofloxcin+metronidalzole IV & oral; Max is 2 day ICU adm.+10 day CPN,pip/tazo+ Metro+cephalexin Cost Range = $7, to $16,668.47

Scenario: A 38 year old female presented with medically refractory ulcerative colitis. She was on steroids and infliximab prior to the presentation. She had past history of laparoscopic hysterectomy and C- section. Hand assisted laparoscopic total proctocolectomy with ileal pouch anal anastomosis and diverting ileostomy was performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination IV Antibiotics Conservative management Post Op Hospital Length of stay (days) 11 Fever Erythema Induration Pain Discharege ICU Care Incubation for 24 – 48 hours with multiple CXR, ABG, WBC, Electrolytes, Creatinine, etc. Repeat CT every 5-7 days Out patient follow up ORGAN / SPACE SSI IV antibiotics + CT guided Drainage Floor Care Tests 1, WBC Count 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. Blood Culture 6. Chest X-Ray 7. URINE Analysis 2 week IV antibiotics 2 week Oral antibiotics Visiting Nurse Home visits + Wound dressing / Home Wound Vac Repeat WBC count 24 – 48 hours IV antibiotics + Operative room Drainage CT Sinogram every 7-10 days Assuming Organ/Space SSI was diagnosed in POD#1 which leaves 10 days of hospital stay: CPT4 codes are reported in parenthesis; Complete Blood Count (85027) one-two times a day X 10 days (including ICU); CT Scan Abdomen w/ contrast (74160) X 1; CT Scan Pelvis w/ contrast (72193) X 1; Blood Draw (36415) X many times; Blood Culture (87040) X 1; Grams Stain (87025) X 1; Antibiotic susceptibility (87186) X 1; Chest X-ray PA & lateral (71020) ; X-ray Abdomen (74000); Urinalysis, routine (81001). IV antibiotics: One of the following is prescribed X 10 days (changed to oral antibiotics once the patient feels better): Piperacillin/ Tazobactam IV; Levofloxacin IV; Cefazolin IV; (+/-) Metronidazole IV. Oral Antibiotics: Either one of the following is prescribed X 10 days (Assuming IV antibiotics are changed into oral antibiotics on the day of discharge): 1. Cephalexin cap; 2. Levofloxacin tab; 3. Augmentin Tab. ICU care for hours (Assuming 48 hours in ICU will have the following investigations and care): ICU room cost (not billed with any CPT Codes): Complete Blood Count X 4 times (85027) ; Chest x-ray portable (71010) X 2; Arterial Blood Gases X 2 (82805); Sodium X 2 (84295); Potassium X 2 (84132); Chlorides X 2 (82435); Phosphorus X 2 (84100); Magnesium X 2 (83735); Blood urea Nitrogen X 2 (84520); Creatinine X 2 (82565); Glucose X 2 (82948); Ionized calcium X 2 (82330); Prothrombin Time X 2 (85610); Activated partial thromboplastin time X 2 (85730); Electro Cardiogram X 1 (93000); Complete Parenteral Nutrition: Adult (CPT Code – not listed);.CT guided drainage: Interventional Radiologist (not billed with any CPT4 code); Contrast injection / Facility Fee (49424); Contrast – LOCM mg/ml (Q9967); Moderate Sedation (99144); Radiological guided drainage (75989). Microbiology of the drainage fluid: General Bacterial Culture (87086) X 1; Grams stain X 1 (87205); Anaerobic Culture X 1 (87075); Antibiotic Susceptibility X 1 (87186). CT Sinogram X 2 (assuming done every 5 days) ; Percutaneous drain catheter w/ contrast (75984); Radiological examination of fistula (76080). Floor Care: Room costs (not billed with any CPT Codes) X 4 days extra stay for SSI. CBC (CPT 85027) $26.16 Total Cost/$32.70 no ICU Blood Draw (CPT 36415) $ Total Cost/ no ICU CT Scan Abdomen w/contrast (CPT 74160) $ Total Cost CT Scan Pelvis w/contrast (CPT $ Total Cost Microbiology of Drainiage Fluid General Bacterial Culture (CPT 87070) $27.83 Total Cost Grams Stain (CPT 87205) $22.10 Total Cost Antibiotic susceptibility (CPT 87186) $29.78 Total Cost ICU Room Cost $5,335,74 Total Cost Other ICU Care $1, Total Cost CT Guided Drainage $ Total Cost CT Sinogram $1,300 Total Cost Other Care $ Total Cost Chest X-Ray & lateral (CPT 71020) $52.89 Total Cost X-Ray Abdomen (CPT 74000) $66.03 Total Cost Urinalysis, routine (CPT 81001) $21.21 Total Cost IV Antibiotics Levofloxacin IV $135.28Total Cost Cefazolin IV $ Total Cost Piperacillin/Tazobactam IV $1, Total Cost Metronidazole Premix $ Total Cost Vancomycin IV $ Total Cost Oral Antibiotics Cephalexin cap $37.80 Total Cost Levofloxacin tab $77.70 Total Cost Augmentin tab $ Total Cost Metronidazole tab $38.22 Total Cost Semiprivate Room $3,503.40/$5, no ICU Total Cost Private Room $3, /$5, no ICU Total Cost Min. is no ICU adm. & no CPN; levofloxcin+metronidalzole IV & oral; Max is 2 day ICU adm.+10 day CPN,pip/tazo+ Metro+cephalexin Cost Range = $9, to $18,951.18

Scenario: A 23 year old male with h/o familial adenomatous polyposis comes presents with anal stricture. He had total proctocolectomy with ileal pouch anal anastomosis. He had anal dilatation with diverting ileostomy for anal stricture. Abdominal exploration with ileal J-pouch excision and end ileostomy was performed. COLORECTAL SURGERY * Diverting Stoma * No diversion History & Physical Examination IV Antibiotics Conservative management Post Op Hospital Length of stay (days) 11 Fever Erythema Induration Pain Discharege ICU Care Incubation for 24 – 48 hours with multiple CXR, ABG, WBC, Electrolytes, Creatinine, etc. Repeat CT every 5-7 days Out patient follow up ORGAN / SPACE SSI IV antibiotics + CT guided Drainage Floor Care Tests 1, WBC Count 2. CT Scan 3. MICROBIOLOGY 4. CULTURE & SENS. 5. Blood Culture 6. Chest X-Ray 7. URINE Analysis 2 week IV antibiotics 2 week Oral antibiotics Visiting Nurse Home visits + Wound dressing / Home Wound Vac Repeat WBC count 24 – 48 hours IV antibiotics + Operative room Drainage CT Sinogram every 7-10 days Assuming Organ/Space SSI was diagnosed in POD#1 which leaves 10 days of hospital stay: CPT4 codes are reported in parenthesis; Complete Blood Count (85027) one-two times a day X 10 days (including ICU); CT Scan Abdomen w/ contrast (74160) X 1; CT Scan Pelvis w/ contrast (72193) X 1; Blood Draw (36415) X many times; Blood Culture (87040) X 1; Grams Stain (87025) X 1; Antibiotic susceptibility (87186) X 1; Chest X-ray PA & lateral (71020) ; X-ray Abdomen (74000); Urinalysis, routine (81001). IV antibiotics: One of the following is prescribed X 10 days (changed to oral antibiotics once the patient feels better): Piperacillin/ Tazobactam IV; Levofloxacin IV; Cefazolin IV; (+/-) Metronidazole IV. Oral Antibiotics: Either one of the following is prescribed X 10 days (Assuming IV antibiotics are changed into oral antibiotics on the day of discharge): 1. Cephalexin cap; 2. Levofloxacin tab; 3. Augmentin Tab. ICU care for hours (Assuming 48 hours in ICU will have the following investigations and care): ICU room cost (not billed with any CPT Codes); Complete Blood Count X 4 times (85027) ; Chest x-ray portable (71010) X 2; Arterial Blood Gases X 2 (82805); Sodium X 2 (84295); Potassium X 2 (84132); Chlorides X 2 (82435); Phosphorus X 2 (84100); Magnesium X 2 (83735); Blood urea Nitrogen X 2 (84520); Creatinine X 2 (82565); Glucose X 2 (82948)’; Ionized calcium X 2 (82330); Prothrombin Time X 2 (85610); Activated partial thromboplastin time X 2 (85730); Electro Cardiogram X 1 (93000).;Complete Parenteral Nutrition: Adult (CPT Code – not listed). Operative room drain placement: Anesthesia cost (Spinal Anesthesia); 2. Anesthesia supplies; 3. Procedure cost; 4. Operative room cost; 5. PACU cost. Microbiology of the drainage fluid: General Bacterial Culture (87086) X 1; Grams stain X 1 (87205); Anaerobic Culture X 1 (87075); Antibiotic Susceptibility X 1 (87186). CT Sinogram X 2 (assuming done every 5 days) : Percutaneous drain catheter w/ contrast (75984); Radiological examination of fistula (76080). Floor Care: Room costs (not billed with any CPT Codes) X 4 days extra stay for SSI. CBC (CPT 85027) $26.16 Total Cost/$32.70 no ICU Blood Draw (CPT 36415) $ Total Cost/ no ICU CT Scan Abdomen w/contrast (CPT 74160) $ Total Cost CT Scan Pelvis w/contrast (CPT $ Total Cost Microbiology of Drainiage Fluid General Bacterial Culture (CPT 87070) $27.83 Total Cost Grams Stain (CPT 87205) $22.10 Total Cost Antibiotic susceptibility (CPT 87186) $29.78 Total Cost IV Antibiotics Levofloxacin IV $135.28Total Cost Cefazolin IV $ Total Cost Piperacillin/Tazobactam IV $1, Total Cost Metronidazole Premix $ Total Cost Vancomycin IV $ Total Cost ICU Room Cost $5,335,74 Total Cost Other ICU Care $1, Total Cost CT Sinogram $1,300 Total Cost Other Care $ Total Cost OR Cost $____ Total Cost PACU Cost (IP 10230) $ Total Cost Chest X-Ray & lateral (CPT 71020) $52.89 Total Cost X-Ray Abdomen (CPT 74000) $66.03 Total Cost Urinalysis, routine (CPT 81001) $21.21 Total Cost Oral Antibiotics Cephalexin cap $37.80 Total Cost Levofloxacin tab $77.70 Total Cost Augmentin tab $ Total Cost Metronidazole tab $38.22 Total Cost Spinal Anesthesia (IP 21885) $1, Total Cost Anesthesia supplies $ Total Cost Semiprivate Room $3,503.40/$5, no ICU Total Cost Private Room $3, /$5, no ICU Total Cost Min. is no ICU adm. & no CPN; levofloxcin+metronidalzole IV & oral; Max is 2 day ICU adm.+10 day CPN,pip/tazo+Metro+cephalexin Cost Range = $11,667,60+ to $21, + Procedure Costs

PATIENT WORKSHEET 1.1: SUPERFICIAL SSI

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PATIENT WORKSHEET 1.1: SUPERFICIAL SSI

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