# Bascom Cleft Lift px for pilondial sinus



## cswan (Apr 13, 2012)

I apologize if I accidentally posted an incomplete thread.  Let me start again.  

I'm a little stumped on how to code this note and would appreciate input.  I'm leaning towards the 11772 alone, but am unclear if an advancement flap should also be coded and/or the sphincteroplasty (looks to me like the sphincter muscles were cut during the pilondial sinus excision, and then repaired).  If the flap should be coded separately, I know I need to get the defect dimensions as those aren't noted.  Here's the note--what do y'all think?

Pt to operation room/anesthesia induced, preop antiobitocs infused.  Pt place in prone postion, all pressure points were padded.  The entire gluteal area midline wounds were clipped of hair, then pt was marked with a marking pen about a 2 cm off of the midline, where the gluteal folds naturally came together.   Next, pt was prepped and draped in standard sterile fashion.  Proposed midline incisional flap was then subcutaneously injected throught its length with a mixture of Marcaine  & epinephrine.

On the left side of the infected pilonidal sinus, incisions were begun on the left midline of the proposed ellipse using a #15 blade knife going 1mm to the right of the unhealed defect.  A skin flap about 5-7mm thick using Bovie cautery was freed from the right and left walls of the cleft.  The chronic abscess cavity was scrubbed clean with gauze of hair and granulation infected tissue.  There were no secondary openings or fistulas seen.  Eschar that was formed from the abscess was incised with Bovie cautery in a cuboidal fashion to take tension off the proposed incision.

Once that flap was made of skin and fat of entire ellipse of the tissue all the way down to the anal margin up to the anal sphincters, then the necrotic, fibrotic granulated tract was also excised and passed off as a specimen.  Pt was noted to have diseased all the way to exposed external sphincter muscle, which was involved with a fibrotic disease tissue, some muscle fibers were cut.  The edges of the external sphincter muscle in the midline location were reapproximated with overlapping sphincteroplasty of two #1 Vicryl sutrues.

Next, the tapes that were previously placed before the case from the buttocks to the table were now released and the buttocks was pushed together into normal position along the previously marked lines at the beginning of the case and the skin flap on the left side was pulled over to the right side.  A stab incision was made in the left upper part of the incision with the Bovie through which a #7 JP fully perforated drain was placed and cut to size.  The wound was irrigated and checked for hemostasis.  There was no bleeding.  Next, using 2-0 Vicyl sutures, the fat was reapproximated and 3 layers to take tension off of the midline as well as to close the gluteal cleft.

Once this was done, the inferior aspect of the flap was rotated around the posterior anus to keep the incision at the midline.  Next, the subdermal layer was reapproximated with interrupted 3-0 Vicryl sutures, in the fashion, the entire cleft was lifted out o infected tissue was removed and a tension-free advancement flap was made with its suture line off the midline towards the right of midline.  Next, using two 3-0 Vicryl sutures, the subdermal skin was closed in a subcuticular fashion and tied to itself in the midline.

Drapes were removed, cleaned up, dried, Benzoin/steris, drain secured, etc. end of px.

Thanks in advance for your help as I expand my horizons...
Cindy L. Swan, CPC
Durango, CO


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## FTessaBartels (Apr 19, 2012)

*Flap can be coded separately*

The flap may be coded separately when coding 11772.

I am also confused about the sphincteroplasty.  Hard to tell whether this was a surgical mishap, or if the disease process required this repair.  Might want to ask the provider for clarification on this. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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