rockylopez
Networker
Hello
I am gearing towards coding this as 56405 but i came across 10060 as well. I wanted to ask for anyone input. Thank you
Pre-procedure diagnosis:
Fournier's gangrene of left mons and left labia
Abscess on left mons pubis with cellulitis
Right lateral labial cellulitis and abscess
Post-procedure diagnosis:
Superficial abscess of the left mons pubis
left labial abscess
Chronic changes of hidradenitis suppurativa
Procedures performed:
Exam under anesthesia
Irrigation drainage of left mons pubis abscess
Irrigation debridement of left left labial abscess
Technique/Procedure:
Patient was taken to the operating room . General anesthesia was obtained without difficulty. Patient was examined under anesthesia findings as noted above. Patient was placed in dorsal lithotomy position. Parts were then prepped and draped in normal sterile fashion using all aseptic precautions. Foley catheter was inserted and the bladder was emptied.
Trauma drape was used to cover the surgical field. Irrigation /debridement performed through elliptical incision of the mons area to include skin and dermis and subcutaneous tissue. Superficial abscess encountered left mons area. Specimen submitted. Deeper tissues revealed viable tissue without gross infection. No dishwater pus. Induration towards the left labia noted with probing of the subcutaneous tissue. Left labial abscess encountered which freely drained through the existing elliptical mons incision/ wound cavity. Hemostat used to probe deep tissue to ensure no loculations of pus, None encountered. Component of extension to the left labia decompressed via her existing wound. Right labia was also probed. Ultimately fascial exposure done revealing viable appearing fascia. Densely adherent subcutaneous tissue integrity to the fascia negates necrotizing fasciitis. No evidence of dishwater pus at that point of time. Intraoperative cultures were obtained. 5 L of pulse irrigation was done using pulse irrigator. Subcutaneous bleeders were cauterized with Bovie. Wound packed with Betadine gauze to the complete depth of the wound.
Kerlix and ABD packs placed on the top.
Specimens removed/altered: ellipse of tissue to include skin/ dermis and subcutaneous tissue with superficial abscesses
Patient tolerated the procedure well and was transferred to recovery room in stable condition.
Dimension of the wound: 10cm x6cmx 3cm
Pre-procedure diagnosis:
Fournier's gangrene of left mons and left labia
Abscess on left mons pubis with cellulitis
Right lateral labial cellulitis and abscess
Post-procedure diagnosis:
Superficial abscess of the left mons pubis
left labial abscess
Chronic changes of hidradenitis suppurativa
Procedures performed:
Exam under anesthesia
Irrigation drainage of left mons pubis abscess
Irrigation debridement of left left labial abscess
Technique/Procedure:
Patient was taken to the operating room . General anesthesia was obtained without difficulty. Patient was examined under anesthesia findings as noted above. Patient was placed in dorsal lithotomy position. Parts were then prepped and draped in normal sterile fashion using all aseptic precautions. Foley catheter was inserted and the bladder was emptied.
Trauma drape was used to cover the surgical field. Irrigation /debridement performed through elliptical incision of the mons area to include skin and dermis and subcutaneous tissue. Superficial abscess encountered left mons area. Specimen submitted. Deeper tissues revealed viable tissue without gross infection. No dishwater pus. Induration towards the left labia noted with probing of the subcutaneous tissue. Left labial abscess encountered which freely drained through the existing elliptical mons incision/ wound cavity. Hemostat used to probe deep tissue to ensure no loculations of pus, None encountered. Component of extension to the left labia decompressed via her existing wound. Right labia was also probed. Ultimately fascial exposure done revealing viable appearing fascia. Densely adherent subcutaneous tissue integrity to the fascia negates necrotizing fasciitis. No evidence of dishwater pus at that point of time. Intraoperative cultures were obtained. 5 L of pulse irrigation was done using pulse irrigator. Subcutaneous bleeders were cauterized with Bovie. Wound packed with Betadine gauze to the complete depth of the wound.
Kerlix and ABD packs placed on the top.
Specimens removed/altered: ellipse of tissue to include skin/ dermis and subcutaneous tissue with superficial abscesses
Patient tolerated the procedure well and was transferred to recovery room in stable condition.
Dimension of the wound: 10cm x6cmx 3cm