AR2728
Expert
I was thinking 10061 would be correct for the following operative report, but the hospital coder mentioned debridement coding-specifically 11000. However, if debridment is coding I think 11042 would be more appropriate. I'm confused whether this should be I&D abscess or debridment. Any suggestions on what is appropriate?
POSTOPERATIVE DIAGNOSIS:
Complex abscess right posterior thigh
OPERATIVE PROCEDURE:
Exam under anesthetic
Wide incision
Debridement, irrigation and packing of complex abscess
The area of induration was down to about 5-6 cm but continued to be tender. The area of pointing was down to 1 cm but had significant fibrinous exudate. Local anesthetic was administered in the form of a field block and then around the area of opening. During injection of local anesthetic laterally, this did come through the 1 cm opening which was on the medial aspect of the area of induration. Swab was inserted through the 1 cm area of opening and specimens were obtained for gram stain and culture. There was a small amount of purulence with significant fibrinous exudate and necrotic debris. Once swabs were obtained the cavity was probed with a mosquito clamp and did extend deep and laterally into a well formed cavity. This appeared to have drained with only a small amount of residual purulence and necrotic tissue. The area of pointing was sharply resected full thickness with a scalpel, removing a 2 mm rim of skin around the area of pointing. The incision was then carried out along the path of the abscess laterally with a small 2-3 mm wide ellipse resected out laterally. This did open up the underlying abscessed cavity. On digital probing this did go down to the muscle out laterally and deep where it extended for about slightly more than 4 cm. The medial aspect of this was where the area of pointing was located as it extended only a small amount, less than 1 cm, medial to the opening. The cavity was widely opened. Surrounding necrotic skin and underlying necrotic subcutaneous tissues were sharply debrided with pickups,
scalpels, scissors, and a curette. This did remove all necrotic tissue. There was no obvious foreign body. Once all necrotic tissue had been debrided and the wound widely drained, it was irrigated under pressure with 3 liters of antibiotic solution. The antibiotic
solution was hooked up to a pressure bag and was then infiltrated through an 18 gauge angio cath. Hemostasis was exact. All necrotic tissue was removed. The wound was then packed with a 2X2 soaked with antibiotic solution, followed by a large bulky
dressing with 4X4's, Kerlex and an ACE wrap.
POSTOPERATIVE DIAGNOSIS:
Complex abscess right posterior thigh
OPERATIVE PROCEDURE:
Exam under anesthetic
Wide incision
Debridement, irrigation and packing of complex abscess
The area of induration was down to about 5-6 cm but continued to be tender. The area of pointing was down to 1 cm but had significant fibrinous exudate. Local anesthetic was administered in the form of a field block and then around the area of opening. During injection of local anesthetic laterally, this did come through the 1 cm opening which was on the medial aspect of the area of induration. Swab was inserted through the 1 cm area of opening and specimens were obtained for gram stain and culture. There was a small amount of purulence with significant fibrinous exudate and necrotic debris. Once swabs were obtained the cavity was probed with a mosquito clamp and did extend deep and laterally into a well formed cavity. This appeared to have drained with only a small amount of residual purulence and necrotic tissue. The area of pointing was sharply resected full thickness with a scalpel, removing a 2 mm rim of skin around the area of pointing. The incision was then carried out along the path of the abscess laterally with a small 2-3 mm wide ellipse resected out laterally. This did open up the underlying abscessed cavity. On digital probing this did go down to the muscle out laterally and deep where it extended for about slightly more than 4 cm. The medial aspect of this was where the area of pointing was located as it extended only a small amount, less than 1 cm, medial to the opening. The cavity was widely opened. Surrounding necrotic skin and underlying necrotic subcutaneous tissues were sharply debrided with pickups,
scalpels, scissors, and a curette. This did remove all necrotic tissue. There was no obvious foreign body. Once all necrotic tissue had been debrided and the wound widely drained, it was irrigated under pressure with 3 liters of antibiotic solution. The antibiotic
solution was hooked up to a pressure bag and was then infiltrated through an 18 gauge angio cath. Hemostasis was exact. All necrotic tissue was removed. The wound was then packed with a 2X2 soaked with antibiotic solution, followed by a large bulky
dressing with 4X4's, Kerlex and an ACE wrap.
