CKindred
Contributor
I just started coding in plastics and I need help with this procedure. I have not been able to come up with a code that supports this information, any information would help. Thanks in advance.
Preopertive Dx: Sacral bleeding, status post wide excision of pilonidal cyst.
Indications: The patient is a 34-year-old male who previously undergone wide excision of a pilonidal cyst over his sacrum measuring approximately 18 x 10 cm. He was noted to have after undergoing wound VAC dressing changes today to have a small area of bleeding,which was treated with silver nitrate. Approximately 1 to 2 hours after undergoing dressing change,the patient was noted to have significant amount of bleeding coming through his VAC dressing. Therefore, I elected to take the patient to the operating room to cauterize the areas of bleeding.
Description of Procedure: After informed consent was obtained, the patient was taken to the operating room where he was placed in the right lateral decubitus position. The patient's sacrum was prepped with Betadine paint, and draped with sterile towels and drapes. Once this had been completed, the areas over the sacrum were cauterized using the Bovie electrocautery.There was no bleeding from the area, which had been treated with silver nitrate earlier. There was bleeding from multiple small areas of the subcutaneous fat as well as overlying the sacrum. After obtaining hemostasis, a Telfa gauze followed by wound VAC sponge and wound VAC dressings were then applied. This was then placed to a continuous suction. At this point, the patient was then turned to the supine position where the axillary dressing was changed as well. Once this had been completed, the patient was taken to recovery.
Preopertive Dx: Sacral bleeding, status post wide excision of pilonidal cyst.
Indications: The patient is a 34-year-old male who previously undergone wide excision of a pilonidal cyst over his sacrum measuring approximately 18 x 10 cm. He was noted to have after undergoing wound VAC dressing changes today to have a small area of bleeding,which was treated with silver nitrate. Approximately 1 to 2 hours after undergoing dressing change,the patient was noted to have significant amount of bleeding coming through his VAC dressing. Therefore, I elected to take the patient to the operating room to cauterize the areas of bleeding.
Description of Procedure: After informed consent was obtained, the patient was taken to the operating room where he was placed in the right lateral decubitus position. The patient's sacrum was prepped with Betadine paint, and draped with sterile towels and drapes. Once this had been completed, the areas over the sacrum were cauterized using the Bovie electrocautery.There was no bleeding from the area, which had been treated with silver nitrate earlier. There was bleeding from multiple small areas of the subcutaneous fat as well as overlying the sacrum. After obtaining hemostasis, a Telfa gauze followed by wound VAC sponge and wound VAC dressings were then applied. This was then placed to a continuous suction. At this point, the patient was then turned to the supine position where the axillary dressing was changed as well. Once this had been completed, the patient was taken to recovery.