nsteinhauser
Expert
If anyone has any thoughts on coding for this op note, I would really appreciate help....
...prepped and draped in the usual sterile fashion. Local anesthesia was infiltrated around the periphery of the open wound which was 3mm to 4mm in diameter. Methylene blue was instilled into the wound and this revealed a large cavity underneath extending laterally and inferiorly. At this point we decided to open up the previous wound. This was fully opened and some chronic inflammatory type of granulation tissue was seen in the subcutaneous tissue and this was all excised as well as all the tissue that was stained with methylene blue. The patient had a lot of oozing as she had before during the surgery. After multiple attempts at electrocauterization we instilled some thrombin and this seemed to help control the bleeding. However, we decided to tack the soft tissue down in an effort to close the wound and this deep tissue was tacked down using 3-0 Vicryl. A Penrose drain was placed underneath this and was brought out through the wound laterally and the drain was secured with 4-0 Monocryl and the skin was closed in layers with 4-0 Monocryl as well. A steril dressing was placed.
The original surgery was excision of hidradenitis and the original dimensions were 11cm x 3cm on the trunk. I look at 10180 but this was not an infection, per se, it was a non-healing surgical wound. I look at 13160 but this wasn't an infectious breakdown - or was it? Or is this complex closure 13101 with the 13102 for the total of 11cm? Any thoughts would be helpful. Thank you!
...prepped and draped in the usual sterile fashion. Local anesthesia was infiltrated around the periphery of the open wound which was 3mm to 4mm in diameter. Methylene blue was instilled into the wound and this revealed a large cavity underneath extending laterally and inferiorly. At this point we decided to open up the previous wound. This was fully opened and some chronic inflammatory type of granulation tissue was seen in the subcutaneous tissue and this was all excised as well as all the tissue that was stained with methylene blue. The patient had a lot of oozing as she had before during the surgery. After multiple attempts at electrocauterization we instilled some thrombin and this seemed to help control the bleeding. However, we decided to tack the soft tissue down in an effort to close the wound and this deep tissue was tacked down using 3-0 Vicryl. A Penrose drain was placed underneath this and was brought out through the wound laterally and the drain was secured with 4-0 Monocryl and the skin was closed in layers with 4-0 Monocryl as well. A steril dressing was placed.
The original surgery was excision of hidradenitis and the original dimensions were 11cm x 3cm on the trunk. I look at 10180 but this was not an infection, per se, it was a non-healing surgical wound. I look at 13160 but this wasn't an infectious breakdown - or was it? Or is this complex closure 13101 with the 13102 for the total of 11cm? Any thoughts would be helpful. Thank you!