# incision exploration



## rkindlund (Feb 3, 2014)

I cannot find a code that seems to fit what my surgeon did here. Any input would be appreciated. Any exploration codes require foreign body removal, and I&D requires drainage by definition, which was not done.

NAME OF PROCEDURE:  Left upper extremity incision exploration and culture x 2.



HISTORY OF PRESENT ILLNESS:  This is a 60-year-old gentleman from San Juan 

Island who developed onset of left upper extremity cellulitis, was admitted to 

the hospital on the 27th and was placed on antibiotics.  Ultrasound showed edema

within the tissues, no fluid collections.  Since the admission, he has had 

increasing left upper extremity discomfort and progressive cellulitis.  Some of 

the skin shows small bullae and CT scan indicates extensive edema as does 

physical examination.  Because of concerns of necrotizing fasciitis or undrained

fluid collection, the patient was taken urgently to the operative suite for 

exploration.



DESCRIPTION OF PROCEDURE:  The patient was placed in supine position undergoing 

general anesthetic.  He was sterilely prepped and draped over the left upper 

extremity.  An initial incision is made along the medial forearm, midway between

the olecranon and wrist.  It was made in a longitudinal fashion for 

approximately 4 to 5 cm.  Upon entering the skin, there is a hemorrhage at all 

levels of tissue.  The lipomatous layer was divided with electrocautery down to 

the level of fascia, which is intact, viable without evidence of purulence nor 

undrained fluid collection.  Cultures were obtained in the deep subcutaneous 

tissue and overlying the fascia and sent for evaluation.  Hemostasis was 

achieved with electrocautery.  Closure was performed with a deep layer of 

interrupted 3-0 Vicryl sutures and the skin was approximated with 3-0 nylon 

vertical mattress sutures.



Attention was then turned towards the upper arm.  On the posterior aspect of the

brachium at its midportion, a longitudinal incision was made for 4 cm.  Again, 

hemorrhage is noted at the level of the skin.  No purulence is identified.  The 

subcutaneous layer is grossly edematous, but without evidence of fasciitis.  The

muscle is soft without compartment syndrome and all levels of tissue including 

dermis, subcutaneous tissue and fascial layer are hemorrhagic and bleed freely. 

Hemostasis was achieved with electrocautery.  Veins in the subcutaneous tissue 

are patent.  Closure was performed with a deep interrupted layer of 3-0 Vicryl 

sutures and the skin was approximated with 3-0 nylon vertical mattress sutures. 

Total blood loss was 25 mL.  The patient tolerated the procedure well.  The 

wounds were covered with Xeroform gauze and absorptive dressing and Kerlix.


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## OCD_coder (Feb 3, 2014)

Procedure #1 - 25028

Procedure #2 - 23920  

I would use these codes as it describes best what was performed than any other CPT code available.  While a "drainage" was not performed per se, remember we don't have to match word for word completely, but "what best describes" the procedure performed.  The surgeon did not go into the bursa, or excise bone so those codes would not be appropriate;  but he/she did go "Deep" beyond the skin, not into the joint (arthrotomy).  An unlisted code would not be correct, IMO.  But I am open to other's opinions on this topic.

I would be willing to bet if you asked the surgeon there was drainage of at least blood as described in the note.


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## rkindlund (Feb 5, 2014)

Thank you so much! That is helpful.


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