Hi all,
Is there a code for placement of multiple subcutaneous drains when it is the primary procedure? Op note follows. Thanks!
Krisan
POSTOPERATIVE DIAGNOSES:
1. No evidence of internal fistulous opening.
2. Multiple drainage sinuses of left ischial abscess cavity with purulent drainage.
PROCEDURE PERFORMED:
1. Anoscopy.
2. Drainage of multiple perianal abscesses with placement of multiple flexible drains, biopsy of tissue.
SPECIMENS:
1. Curetting of fistulous tracts.
2. Biopsy of superficial fistula tract including overlying skin.
FINDINGS: Numerous openings on the left ischial area with draining purulence. Most of them interconnected below the skin without any clear connection to the anal canal.
DESCRIPTION OF PROCEDURE: The perineum was then prepped and draped in the usual sterile manner. Upon raising the patient to the lithotomy position, the patient was noted to have numerous openings, several of which were draining out obvious purulent fluid. The initial examination was the anoscopy. Extensive anoscopy was performed quite high. Digital examination revealing no obvious pathology, no palpable fistula tract was identified. The remainder of the anoscopy was normal other than a moderate amount of grade I and grade II internal hemorrhoids without evidence of active bleeding or stigmata of recent bleeding. More importantly, no obvious fistulous opening was identified. The area of the inflammation was examined. There was appeared to be chronic scarring. This grossly appeared to be consistent with hidradenitis versus fistulizing Crohn's disease. The extent of the disease was entirely on the left side however, and with palpation of the area there was a fistula straining. There was a dominant opening in the center of all the inflammation and fistula strains. This was gently probed and the probe easily passed medially and anteriorly to the space in the perianal area; however, there was no fistulous opening in the area. There was no inflammation in this area where it passed. There appeared to be a fairly extensive cavity, although no inflammation was identified. The other fistula tracts were gently probed, several of them were cutaneous to cutaneous but the bulk of them connected ultimately to the cavity, the major cavity and medial to the anus. In an attempt to identify internal fistulous opening, the dominant was injected with hydrogen peroxide with extensive drainage of the foaming areas from almost all of the external skin openings in the left ischial area. There was no evidence of any foaming or drainage or bleeding within the anal canal even with manipulation and pressure. Curiously however, the gas of hydrogen peroxide did seem to track along the submucosal layer despite at no time exiting or draining into the anal canal or distal rectum. As no fistulous opening was clearly identified, it was not attempted to extend the probe into the anal canal at this time. The biopsies were taken first by curetting the major fistulous tracts and cavities and the second one of the superficial tracts was opened and a portion of the skin and tract was removed and sent for pathology. Hemostasis was obtained using electrocautery. It was felt that debriding the area would leave a large area that would be difficult to provide coverage for and therefore it was elected to simply ensure adequate drainage of the complex abscess. This was performed by placing vessel loop soft drains between the various openings, many of them through the dominant opening tying them each other in a loose noncutting Seton in like fashion. A total of 4 of these were placed. The most posterior, one of these extended the farthest to the dominant opening. At this point, all the identified openings were held open with drainage and it was felt that this would allow adequate drainage and healing provided this did not represent Crohn's disease. The entire area was then gently irrigated washing away the hydrogen peroxide. The entire area was then also infiltrated with 0.5% Marcaine with epinephrine. Antibiotic ointment was placed on the open biopsy site and a large fluffy absorbent dressing was placed over the operative site. Prior to placing the dressing, an anoscopy was again performed to ensure that no occult fistulous opening had been identified in the interim. None being identified, the procedure was terminated. Patient tolerated the procedure well. There were no complications. There was minimal blood loss. The patient was extubated, taken to recovery, awake and breathing well on his own.
Is there a code for placement of multiple subcutaneous drains when it is the primary procedure? Op note follows. Thanks!
Krisan
POSTOPERATIVE DIAGNOSES:
1. No evidence of internal fistulous opening.
2. Multiple drainage sinuses of left ischial abscess cavity with purulent drainage.
PROCEDURE PERFORMED:
1. Anoscopy.
2. Drainage of multiple perianal abscesses with placement of multiple flexible drains, biopsy of tissue.
SPECIMENS:
1. Curetting of fistulous tracts.
2. Biopsy of superficial fistula tract including overlying skin.
FINDINGS: Numerous openings on the left ischial area with draining purulence. Most of them interconnected below the skin without any clear connection to the anal canal.
DESCRIPTION OF PROCEDURE: The perineum was then prepped and draped in the usual sterile manner. Upon raising the patient to the lithotomy position, the patient was noted to have numerous openings, several of which were draining out obvious purulent fluid. The initial examination was the anoscopy. Extensive anoscopy was performed quite high. Digital examination revealing no obvious pathology, no palpable fistula tract was identified. The remainder of the anoscopy was normal other than a moderate amount of grade I and grade II internal hemorrhoids without evidence of active bleeding or stigmata of recent bleeding. More importantly, no obvious fistulous opening was identified. The area of the inflammation was examined. There was appeared to be chronic scarring. This grossly appeared to be consistent with hidradenitis versus fistulizing Crohn's disease. The extent of the disease was entirely on the left side however, and with palpation of the area there was a fistula straining. There was a dominant opening in the center of all the inflammation and fistula strains. This was gently probed and the probe easily passed medially and anteriorly to the space in the perianal area; however, there was no fistulous opening in the area. There was no inflammation in this area where it passed. There appeared to be a fairly extensive cavity, although no inflammation was identified. The other fistula tracts were gently probed, several of them were cutaneous to cutaneous but the bulk of them connected ultimately to the cavity, the major cavity and medial to the anus. In an attempt to identify internal fistulous opening, the dominant was injected with hydrogen peroxide with extensive drainage of the foaming areas from almost all of the external skin openings in the left ischial area. There was no evidence of any foaming or drainage or bleeding within the anal canal even with manipulation and pressure. Curiously however, the gas of hydrogen peroxide did seem to track along the submucosal layer despite at no time exiting or draining into the anal canal or distal rectum. As no fistulous opening was clearly identified, it was not attempted to extend the probe into the anal canal at this time. The biopsies were taken first by curetting the major fistulous tracts and cavities and the second one of the superficial tracts was opened and a portion of the skin and tract was removed and sent for pathology. Hemostasis was obtained using electrocautery. It was felt that debriding the area would leave a large area that would be difficult to provide coverage for and therefore it was elected to simply ensure adequate drainage of the complex abscess. This was performed by placing vessel loop soft drains between the various openings, many of them through the dominant opening tying them each other in a loose noncutting Seton in like fashion. A total of 4 of these were placed. The most posterior, one of these extended the farthest to the dominant opening. At this point, all the identified openings were held open with drainage and it was felt that this would allow adequate drainage and healing provided this did not represent Crohn's disease. The entire area was then gently irrigated washing away the hydrogen peroxide. The entire area was then also infiltrated with 0.5% Marcaine with epinephrine. Antibiotic ointment was placed on the open biopsy site and a large fluffy absorbent dressing was placed over the operative site. Prior to placing the dressing, an anoscopy was again performed to ensure that no occult fistulous opening had been identified in the interim. None being identified, the procedure was terminated. Patient tolerated the procedure well. There were no complications. There was minimal blood loss. The patient was extubated, taken to recovery, awake and breathing well on his own.