Can someone else please take a look at this op report and tell me what your thoughts would be about the code(s)? A consulting company is telling us to use 30430 but not sure if I agree. I was thinking something like 30020 & 20912? HELP!!!!PREOPERATIVE DIAGNOSIS:
1. Nasal tip infection.
POSTOPERATIVE DIAGNOSIS:
1. Nasal tip infection with retained non-absorbed suture.
OPERATION PERFORMED:
1. Open incision and drainage of infection with removal of suture abscess.
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: The patient is someone who underwent functional and cosmetic nasal surgery at the end of November 2009. She was doing well, but then developed some extreme erythema over the nasal tip region with tenderness. She was placed antimicrobial therapy, and the infection did resolve significantly. However, there was still residual swelling and retraction.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was brought to the operating room and placed supine on the operating room table. General anesthesia was administered, and the patient was intubated without difficulties. The eyes were taped shut for protection, and the patient was prepped and draped in a suitable fashion for nasal surgery. A time-out confirmed the patient and procedure. Approximately 2 mL of 1% lidocaine with 1:100,000 of epinephrine were injected into the nasal tip region and into the incision, which had been previously made across the midline portion of the columella. Following sufficient time for local anesthetic and vasoconstrictive effect, the #11 blade was used to open the previously made gull wing incision. A skin flap was elevated off of the lower lateral cartilages, and the patient was noted to have significant scar tissue over an area anteriorly. This was carefully resected with the iris scissors and a suture was noted, which had not absorbed. It was a Vicryl suture, which would have typically been absorbed by this time. This was removed in its entirety along with some of the scar tissue that was around the area. There was no purulence noted. A small portion of cartilage was harvested from the septum anteriorly and placed in a pocket inferior to the incision to help prevent the retraction, which was forming from the infection.
The incision was then closed using a 5-0 black nylon and a 6-0 black nylon in an interrupted fashion. The marginal incisions were closed using a 4-0 chromic suture. A 4-0 plain on a mini Keith needle was used to reapproximate the mucoperichondrial flap that had been elevated for the purposes of harvesting the cartilage. Benzoin was placed over the nasal dorsum, and Steri-Strips were applied. The patient did have a melanotic nevus on the left nasal dome, which had been removed previously. She had some slight regrowth there and this was gently addressed with the needle-tip Bovie. The oropharynx was suctioned. The patient was returned to the anesthesiologist for reversal of the anesthetic. The patient was awakened in the operating room, extubated, and brought to the recovery room in excellent condition breathing spontaneously. There were no complications. All needle and sponge count were correct x2 at the end of the procedure.
Thank you to all my fellow coders out there!
Susan