# Seton Placement vs I&D of Abcess



## LeaHarris (Sep 20, 2016)

I am not familiar with billing placement of seton.  Is this only a billable procedure with anal procedures?  Can a seton placement and an I&D billed at the same time?
Here is my scenario:  (Thanks in advance!)

HPI 

Patient is a 17 year old female here today for wound check and concerns for infection

Packing fell out yesterday, unable to re-place it
Lots of green/white/yellow drainage.
Slight smell. *
Top opening is completely closed. *
Frustrated

No allergy to lidocaine with epi. Has been used before. *
**

Patient Active Problem List*
*	Diagnosis*	Date Noted*
•*	Hydradenitis*	09/17/2016*
•*	Abscess of skin*	01/28/2015*
•*	Acne*	07/15/2014*
•*	Immunizations up to date*	07/15/2014*
*	*	8/1/16
*
•*	Obesity (BMI 30-39.9)*	07/15/2014*

**

	Past Medical History 

Past Medical History*
Diagnosis*	Date*
•*	Acne*	*
•*	ACL injury tear*	*
•*	Left ankle sprain*	*


**

	Past Surgical History 

Past Surgical History*
Procedure*	Laterality*	Date*
•*	Arthroscopy, knee, dx, w/wo synovial bx (sep proc)*	*	*
*	*	torn ACL*


**

	Social History 

Social History*
**

Social History*
•*	Marital Status:*	N/A*
*	*	Spouse Name:*	N/A*
•*	Number of Children:*	N/A*
•*	Years of Education:*	N/A*
**

Occupational History*
•*	Not on file.*
**

Social History Main Topics*
•*	Smoking status:*	Never Smoker *
•*	Smokeless tobacco:*	Never Used*
•*	Alcohol Use:*	No*
•*	Drug Use:*	Not on file*
•*	Sexual Activity:*	No*
**

Other Topics*	Concern*
•*	Not on file*
**

Social History Narrative*
*	7/15/14* Just moved from Arizona.* Moved for family.*
*	*
*	10/3/14 Interested in starting an LGBT group in her high school and attending Pride, not sure of a support structure to get this started. Identifies as straight.*
*	*
*	8/17/16 Going into senior year. Excited about AP history. Wants to be a history teacher*




	Family History 
	No family history on file.


Review of Systems 
Unable to perform ROS
Constitutional: Negative for fever and chills. 
Psychiatric/Behavioral: The patient is nervous/anxious.* 



*
Objective 	
*

	Vitals 

Filed Vitals:*
*	09/19/16 0845*
BP:*	131/73*
Pulse:*	73*
Temp:*	97.3 °F (36.3 °C)*
TempSrc:*	Oral*
Resp:*	16*
Height:*	5' 3" (1.6 m)*
Weight:*	202 lb (91.627 kg)*
SpO2:*	98%*


Estimated body mass index is 35.79 kg/(m^2) as calculated from the following:
* Height as of this encounter: 5' 3" (1.6 m).
* Weight as of this encounter: 202 lb (91.627 kg).
98%ile (Z=2.07) based on CDC 2-20 Years BMI-for-age data using vitals from 9/19/2016.


Physical Exam 
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No distress. 
HENT: *
Head: Normocephalic and atraumatic. 
Eyes: EOM are normal. 
Pulmonary/Chest: Effort normal. No respiratory distress. 
Neurological: She is alert and oriented to person, place, and time. 
Skin: Rash noted. She is not diaphoretic. 
Intramammary fold with draining wound. Formerly open tract superiorly and inferiorly. Top opening closed and scabbed. Bottom opening draining white pus with pressure. 
Significant scarring and smaller comedones surrounding wound
TTP 
Psychiatric: 
Tearful during procedure but appropriate 


Procedure Note
Procedure - Incision and drainage of abcess
PARQA regarding procedure.* Patient wishes to proceed.* Area prepped in a sterile fashion.* Area numbed with 4 mL 1% Lidocaine with epinephrine.* 11 blade scalpel used to lance superior portion of sinus tract.* There was drainage of 3 mL of purulent material from the abcess.* Wound culture not obtained.* Curved hemostat was used to ensure complete drainage of the tract and to open the tract. Wound was then profusely irrigated with 20 mL of sterile saline. Sterile glove cut into 1 inch long strip and passed through the tract using the curved hemostat. Glove strip was tied using surgical knots. The wound was re-irrigated and wiped clean. THe wound was then covered with gauze. There were no complications to procedure.* Patient tolerated the procedure well.* Patient was instructed as below. 


*
Assessment and Plan 	
Patient is a 17 year old female with hydradenitis here for supperative tract.

L02.213 Cutaneous abscess of chest wall
L70.0 Acne vulgaris
L73.2 Hydradenitis* (primary encounter diagnosis)
Had been closed at the top and packed from below, but packing fell out and became supperative
Seton made from sterile glove placed and tract re-opened sharply
Plan : **PLACEMENT, SETON
********** *STOP Clindamycin
************Start doxycycline 100mg BID for prevention of future hydradenitis flairs
************Other options to consider in the future, may be candidate for metformin
************Counseled per patient instructions


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## danskangel313 (Sep 20, 2016)

It reads to me like the I&D was done during this encounter and the seton placement was planned for the future.


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