Please see below. What CPT would I use for the vascular graft exploration? Any help would be appreciated---
POSTOPERATIVE DIAGNOSES:
1. Left thigh and pelvic area abscesses.
2. Vascular graft of the left upper extremity.
OPERATION PERFORMED:
1. Incision and drainage of the left thigh and pelvic area abscesses.
2. Exploration of vascular graft of the left lower extremity.
ANESTHESIA:
General.
DESCRIPTION OF PROCEDURE:
The patient had placement of the left thigh bovine arteriovenous graft approximately 4 weeks ago. The patient has superior vena cava occlusion. The vascular graft remains patent, but the patient presented recently with abscess formation in the left groin area. Concern was that the graft itself may be involved in the septic process. The patient had bedside drainage of the abscess and some purulent content was obtained from there, but patient continues to have fluctuation in this area and fluctuation extends more proximally towards the pelvic region. It was decided to bring the patient to the operating room for incision and drainage of the left groin area and exploration of vascular graft. Under general anesthesia, sterile conditions, the patient in supine position. A 2 cm long incision was placed at the left inguinal area. The cavity was encountered here deep to the fascia. A small amount of turbid content was drained from the proximal thigh area as well as from the area just to the pubic bone. Culture and sensitivity was obtained for aerobic and anaerobic microorganisms. Subcutaneous tissues were sharply debrided with Adson forceps and Metzenbaum scissors. Excisional debridement of the fascia was performed. Vascular graft itself was not exposed to the septic process. Vascular graft was patent with low resistance flow Doppler signals during intraoperative ultrasound evaluation. Wound was irrigated copiously with sterile saline solution. Wound was carefully checked for hemostasis. Wound was dressed with sterile gauze, absorbent dressing was applied. The procedure was tolerated well.
POSTOPERATIVE DIAGNOSES:
1. Left thigh and pelvic area abscesses.
2. Vascular graft of the left upper extremity.
OPERATION PERFORMED:
1. Incision and drainage of the left thigh and pelvic area abscesses.
2. Exploration of vascular graft of the left lower extremity.
ANESTHESIA:
General.
DESCRIPTION OF PROCEDURE:
The patient had placement of the left thigh bovine arteriovenous graft approximately 4 weeks ago. The patient has superior vena cava occlusion. The vascular graft remains patent, but the patient presented recently with abscess formation in the left groin area. Concern was that the graft itself may be involved in the septic process. The patient had bedside drainage of the abscess and some purulent content was obtained from there, but patient continues to have fluctuation in this area and fluctuation extends more proximally towards the pelvic region. It was decided to bring the patient to the operating room for incision and drainage of the left groin area and exploration of vascular graft. Under general anesthesia, sterile conditions, the patient in supine position. A 2 cm long incision was placed at the left inguinal area. The cavity was encountered here deep to the fascia. A small amount of turbid content was drained from the proximal thigh area as well as from the area just to the pubic bone. Culture and sensitivity was obtained for aerobic and anaerobic microorganisms. Subcutaneous tissues were sharply debrided with Adson forceps and Metzenbaum scissors. Excisional debridement of the fascia was performed. Vascular graft itself was not exposed to the septic process. Vascular graft was patent with low resistance flow Doppler signals during intraoperative ultrasound evaluation. Wound was irrigated copiously with sterile saline solution. Wound was carefully checked for hemostasis. Wound was dressed with sterile gauze, absorbent dressing was applied. The procedure was tolerated well.