AR2728
Expert
Here's the lengthy op report from my surgeon who covers wound clinic. I'm confused on what procedure to bill for this and suppose I'm thrown off more by his description of procedure....stating to bill for wide I&D and debridement and he will question me about this if both are not billed. So, I need backup before I even begin. I apologize for the way this looks when posted, but I copied and pasted what I could and had issues making it look pretty.
The patient did have a 12-15 cm area of erythema and cellulitis around a 6-8 cm area of induration and pointing. In the middle of this was about a 4-6 cm area of blistering and a small area of questionable necrosis right over the tip. This was very tense and indurated with what appeared to be underlying
palpable fluid. Ultrasound had shown an underlying fluid collection but with good blood flow. A skin wheal was raised after intravenous sedation. An 18 gauge needle was inserted and approximately 0.5 to 1 cc of non-clotting blood was obtained and was placed on swabs and sent for STAT gram stain and culture. Further local was the injected over the area of pointing which was in the middle of approximately 6 cm blistered area. A longitudinal incision was made over this for 2.5 cm to avoid parallel skin incision. This was carried down through the skin and to the subcutaneous tissues. Once in the
subcutaneous tissues, the patient did have edematous subcutaneous tissues. The tissues were opened up in the subcutaneous space with a small clear fluid collection underneath the area of pointing, opened up and drained. There was no purulence or odor. There was edema fluid. The subcutaneous tissues were opened up underneath the entire 6 cm area of pointing and only clear edema fluid was drained. The underlying subcutaneous tissues had edema but were intact and were viable. There was no ischemic fat visualized. The skin edges on both sides of the 2.5 cm incision were trimmed back about 7-8 mm back to
obviously bleeding skin which was viable. There was no evidence of necrosis more than a small 2.5 cm area of necrosis of any necrotic skin. There was epidermolysis with thesloughed epidermis sharply debrided with a curette, knife, pickups and scissors. Remaining skin was viable. Once the area was opened up and the pocket of serous fluid was drained, the color was markedly improved and the tenseness was markedly improved. Induration was markedly decreased. The patient did feel better at that point by his report. The wound was carefully evaluated visually and the superficial fascia
underneath the incision was intact and healthy. The muscle was palpably intact and was not boggy or inflamed. This was consistent with the ultrasound findings. The superficial fascia was also viable. Skin edges were viable with good blood flow. There was no evidence of necrotizing skin infection. The area was markedly improved with drainage of fluid. The cavity which had been drained of fluid and was consistent with a seroma was relatively small and about 2-3 cm. The cavity was opened up. Subcutaneous tissues were opened up and irrigated under pressure with antibiotic solution. The skin incision
was then loosely re-approximated with a single vertical mattress suture of 4-0 nylon following which the wound was packed around the nylon suture with ?" Nu-Gauze followed by a large bulky dressing, Kerlix and an ace wrap. The patient was awakened and taken to recovery in stable condition. Blood loss was less than 5 cc. Fluids included 850 of crystalloid. Necrotic skin edges which were fairly minimal and necrotic epidermal tissue was sent to pathology. Swabs from the fine needle aspirate which drew nonclotting blood were sent for STAT gram stain and culture. The patient tolerated the procedure well.
The patient did have a 12-15 cm area of erythema and cellulitis around a 6-8 cm area of induration and pointing. In the middle of this was about a 4-6 cm area of blistering and a small area of questionable necrosis right over the tip. This was very tense and indurated with what appeared to be underlying
palpable fluid. Ultrasound had shown an underlying fluid collection but with good blood flow. A skin wheal was raised after intravenous sedation. An 18 gauge needle was inserted and approximately 0.5 to 1 cc of non-clotting blood was obtained and was placed on swabs and sent for STAT gram stain and culture. Further local was the injected over the area of pointing which was in the middle of approximately 6 cm blistered area. A longitudinal incision was made over this for 2.5 cm to avoid parallel skin incision. This was carried down through the skin and to the subcutaneous tissues. Once in the
subcutaneous tissues, the patient did have edematous subcutaneous tissues. The tissues were opened up in the subcutaneous space with a small clear fluid collection underneath the area of pointing, opened up and drained. There was no purulence or odor. There was edema fluid. The subcutaneous tissues were opened up underneath the entire 6 cm area of pointing and only clear edema fluid was drained. The underlying subcutaneous tissues had edema but were intact and were viable. There was no ischemic fat visualized. The skin edges on both sides of the 2.5 cm incision were trimmed back about 7-8 mm back to
obviously bleeding skin which was viable. There was no evidence of necrosis more than a small 2.5 cm area of necrosis of any necrotic skin. There was epidermolysis with thesloughed epidermis sharply debrided with a curette, knife, pickups and scissors. Remaining skin was viable. Once the area was opened up and the pocket of serous fluid was drained, the color was markedly improved and the tenseness was markedly improved. Induration was markedly decreased. The patient did feel better at that point by his report. The wound was carefully evaluated visually and the superficial fascia
underneath the incision was intact and healthy. The muscle was palpably intact and was not boggy or inflamed. This was consistent with the ultrasound findings. The superficial fascia was also viable. Skin edges were viable with good blood flow. There was no evidence of necrotizing skin infection. The area was markedly improved with drainage of fluid. The cavity which had been drained of fluid and was consistent with a seroma was relatively small and about 2-3 cm. The cavity was opened up. Subcutaneous tissues were opened up and irrigated under pressure with antibiotic solution. The skin incision
was then loosely re-approximated with a single vertical mattress suture of 4-0 nylon following which the wound was packed around the nylon suture with ?" Nu-Gauze followed by a large bulky dressing, Kerlix and an ace wrap. The patient was awakened and taken to recovery in stable condition. Blood loss was less than 5 cc. Fluids included 850 of crystalloid. Necrotic skin edges which were fairly minimal and necrotic epidermal tissue was sent to pathology. Swabs from the fine needle aspirate which drew nonclotting blood were sent for STAT gram stain and culture. The patient tolerated the procedure well.