rrrobinson05
Contributor
I'm Looking for help in coding this surgery. I don't have much experience with these types of procedures. Any advice and/or insight would be sincerely appreciated. I'm looking at 38760 for the lymphadenopathy. I'm not sure about the excision of chronic draining sinus.
Pre-operative Diagnosis: 1) chronic right groin wound 2) lymphadenopathy
Post-operative Diagnosis: same
Procedure: 1) right groin dissection and lymphadenectomy 2) excision of chronic draining sinus
Indications: Patient is a 7 y.o. male presenting with a persistent draining wound and sinus in his right groin concerning for possible atypical mycobacterium. Dr. Clancy recommended excision and an extensive panel of tests to further evaluate. Informed consent was obtained. Weight: 26.5 kg (58 lb 6.8 oz)
Operative Details: Patient was brought to the operating room where they underwent general anesthesia. Patient was then prepped and draped in the usual fashion. An elliptical incision was made encompassing the open wound extending to clean healthy skin edges. The subcutaneous tissue was taken down to the fascia and all palpable lymphatic tissue medial of the femoral vessels was included in the specimen. The saphenous vein was taken between 3-0 vicryl ties. The superior edge of the wound was extending longitudinally towards the groin to allow better visualization of the involved lymph nodes in the proximity of the femoral vein. The specimen was passed off the field and sent to micro for a battery of testing. The wound was irrigated. Primary closure was achieved with approximation of the subcutaneous tissue and dermis with interrupted 3-0 vicryl sutures. The skin was closed with two separate running 4-0 monocryl in a subcuticular fashion. The wound was dressed with dermabond and steristrips. There were no apparent complications and the procedure was well tolerated.
Pre-operative Diagnosis: 1) chronic right groin wound 2) lymphadenopathy
Post-operative Diagnosis: same
Procedure: 1) right groin dissection and lymphadenectomy 2) excision of chronic draining sinus
Indications: Patient is a 7 y.o. male presenting with a persistent draining wound and sinus in his right groin concerning for possible atypical mycobacterium. Dr. Clancy recommended excision and an extensive panel of tests to further evaluate. Informed consent was obtained. Weight: 26.5 kg (58 lb 6.8 oz)
Operative Details: Patient was brought to the operating room where they underwent general anesthesia. Patient was then prepped and draped in the usual fashion. An elliptical incision was made encompassing the open wound extending to clean healthy skin edges. The subcutaneous tissue was taken down to the fascia and all palpable lymphatic tissue medial of the femoral vessels was included in the specimen. The saphenous vein was taken between 3-0 vicryl ties. The superior edge of the wound was extending longitudinally towards the groin to allow better visualization of the involved lymph nodes in the proximity of the femoral vein. The specimen was passed off the field and sent to micro for a battery of testing. The wound was irrigated. Primary closure was achieved with approximation of the subcutaneous tissue and dermis with interrupted 3-0 vicryl sutures. The skin was closed with two separate running 4-0 monocryl in a subcuticular fashion. The wound was dressed with dermabond and steristrips. There were no apparent complications and the procedure was well tolerated.