gina_marie
Contributor
Any help is appreciated. We have some disagreement of which code should be billed for the following procedure. Thank you
Pre-op. Diagnosis: Acute cervical wound hematoma.
Post-op. Diagnosis: Same as pre-op diagnosis
Operation: Exploration of the cervical wound for an evacuation of the prevertebral and soft tissue neck hematoma and placement of a 10-French JP drain.
Details of Procedure:
The patient taken to the operating room and given IV sedation. The patient was placed in 30 degrees of head of the bed elevated position. Neck was prepped with ChloraPrep and draped in sterile fashion, 10mL of 1% lidocaine with epinephrine was used to locally anesthetize the skin. A 10-blade scalpel was used to incise the incision. The wound was explored and there was some acute solid hematoma within the neck wound cavity and in the prevertebral space and this was evacuated and washed out with vancomycin irrigation and then patient was placed under general endotracheal anesthesia after the trachea was visible and then again, the wound was prepped and draped in sterile fashion. An additional irrigation with vancomycin and gentamicin irrigation was performed. No obvious bleeding source were to be identified and no gross hematoma or acute bleeding were seen. A 10-French Hemovac drain was placed over the prevertebral space over the anterior cervical plate and tunneled away from the skin incision and connected to a sterile drainage bag. The wound was closed in multiple layers, 3-0 Vicryl suture for the platysma and subcutaneous layer, 4-0 Monocryl suture for the skin in subcuticular fashion followed by Dermabond, followed by sterile dressing. The patient tolerated the procedure well. The patient was extubated and taken to the recovery suite in stable condition.
Thank you for the help.
Pre-op. Diagnosis: Acute cervical wound hematoma.
Post-op. Diagnosis: Same as pre-op diagnosis
Operation: Exploration of the cervical wound for an evacuation of the prevertebral and soft tissue neck hematoma and placement of a 10-French JP drain.
Details of Procedure:
The patient taken to the operating room and given IV sedation. The patient was placed in 30 degrees of head of the bed elevated position. Neck was prepped with ChloraPrep and draped in sterile fashion, 10mL of 1% lidocaine with epinephrine was used to locally anesthetize the skin. A 10-blade scalpel was used to incise the incision. The wound was explored and there was some acute solid hematoma within the neck wound cavity and in the prevertebral space and this was evacuated and washed out with vancomycin irrigation and then patient was placed under general endotracheal anesthesia after the trachea was visible and then again, the wound was prepped and draped in sterile fashion. An additional irrigation with vancomycin and gentamicin irrigation was performed. No obvious bleeding source were to be identified and no gross hematoma or acute bleeding were seen. A 10-French Hemovac drain was placed over the prevertebral space over the anterior cervical plate and tunneled away from the skin incision and connected to a sterile drainage bag. The wound was closed in multiple layers, 3-0 Vicryl suture for the platysma and subcutaneous layer, 4-0 Monocryl suture for the skin in subcuticular fashion followed by Dermabond, followed by sterile dressing. The patient tolerated the procedure well. The patient was extubated and taken to the recovery suite in stable condition.
Thank you for the help.