A physician in our office, performed a procedure that I am having trouble coding and I was hoping that I would be able to get some help in figuring out how to bill this out.
He performed an Excision of abscess and sinus tract. The patient had a chronic clitoral hood abscess with sinus tract. This is what the operative report states:
Pre/Post Operative Diagnosis: Chronic clitoral hood abscess with sinus tract.
Procedure: Excision of abscess and sinus tract.
Description of procedure: The patient was taken to the operative suite where she was given general anesthesia. She was then placed in dorsal lithotomy position with Allen stirrups. She was sterilely prepped and draped in the usual fashion. The area was shaved with sterile shaver and the sinus tract was grasped with a Babcock for better exposure. A 3 cm incision was undermined with Metzenbaum scissors. The tract was then grasped again with the Babcock and the adventitia around it was excised. Turing this process, the tract was opened and probed to find the proximal and distal ends. The entire tract was removed in 1 piece. There was minimal bleeding . The area was irrigated with bacitracin solution. a culture was obtained from the tract. The part of the incision was closed in a running fashion with 4-0 Vicryl. However, with 1 cm portion was left open for drainage. There was minimal bleeding at completion of procedure. The patient was extubated, awake, in stable condition upon transfer to the recovery room. She l be discharged home when fully awake and stable. Postoperative precautions have been given.
I have looked in every book, website and even asked many other offices about how to bill out this procedure with no luck. Am I going to have to bill out an unspecified code?
Thank you in advance for helping me with this difficult question.
He performed an Excision of abscess and sinus tract. The patient had a chronic clitoral hood abscess with sinus tract. This is what the operative report states:
Pre/Post Operative Diagnosis: Chronic clitoral hood abscess with sinus tract.
Procedure: Excision of abscess and sinus tract.
Description of procedure: The patient was taken to the operative suite where she was given general anesthesia. She was then placed in dorsal lithotomy position with Allen stirrups. She was sterilely prepped and draped in the usual fashion. The area was shaved with sterile shaver and the sinus tract was grasped with a Babcock for better exposure. A 3 cm incision was undermined with Metzenbaum scissors. The tract was then grasped again with the Babcock and the adventitia around it was excised. Turing this process, the tract was opened and probed to find the proximal and distal ends. The entire tract was removed in 1 piece. There was minimal bleeding . The area was irrigated with bacitracin solution. a culture was obtained from the tract. The part of the incision was closed in a running fashion with 4-0 Vicryl. However, with 1 cm portion was left open for drainage. There was minimal bleeding at completion of procedure. The patient was extubated, awake, in stable condition upon transfer to the recovery room. She l be discharged home when fully awake and stable. Postoperative precautions have been given.
I have looked in every book, website and even asked many other offices about how to bill out this procedure with no luck. Am I going to have to bill out an unspecified code?
Thank you in advance for helping me with this difficult question.