AT2728
Expert
The thorn in my side-Debridements, I'm always left re-reading and searching and hoping that I am coding correctly. Here's the scrubbed op note that has me stuck.
Preop Diag: left leg abscess
Procedure?: I&D
Indications: ...left lower leg chain saw injury 6 days ago seen in ER and I&D performed at the time, presents with swelling, ultrasound showed fluid collection, appears to be abcess...
Procedure: ....sutures removed, large hematoma underneath the wound, minimal purulence, wound debrided with curette, coupiusly irrigated under pulsatile lavage with 9 liters salien. JP drain placed, wound closed loosely, sterile dressing and short leg splint applied.
The meat of the op note is all there, it is extemely brief in details. Do I simply go with abscess I&D? However, no true incision was made. He does not go into detail regarding the depth of debridement either. I'm really not sure where to go with this.
Preop Diag: left leg abscess
Procedure?: I&D
Indications: ...left lower leg chain saw injury 6 days ago seen in ER and I&D performed at the time, presents with swelling, ultrasound showed fluid collection, appears to be abcess...
Procedure: ....sutures removed, large hematoma underneath the wound, minimal purulence, wound debrided with curette, coupiusly irrigated under pulsatile lavage with 9 liters salien. JP drain placed, wound closed loosely, sterile dressing and short leg splint applied.
The meat of the op note is all there, it is extemely brief in details. Do I simply go with abscess I&D? However, no true incision was made. He does not go into detail regarding the depth of debridement either. I'm really not sure where to go with this.