AR2728
Expert
I need some input on this. Physician billed/performed 46050 for a perianal abscess two days later patient presents back 2 days later and physician documents the following:
The cavity appears to be collapsing but he continues to have about a 5.0 cm cavity if not slightly bigger extending posterior from the excision. I did discuss options with the patient including continuing with packing changes. Currently this is significantly better but because of the large size of the cavity, I did recommend that we proceed to exploring the wound sterilely and place a drain. He was placed in the prone position. Buttock cheeks were spread apart and he was prepped and draped sterilely. Local anesthetic with 1% Lidocaine with epinephrine was injected. The wound was explored and probed and the cavity is somewhat decreased but continues with about 5.0 cm area of open cavity. There is some seropurulent drainage but for the most part this is well drained. I did place a Penrose drain in the cavity directed this posteriorly. This was laid flat and was directed to the distant part of the cavity digitally. Drain was then tacked to the skin with #2 nylon sutures. Sterile dressing was placed.
Would you consider this all part of the original global package?
The cavity appears to be collapsing but he continues to have about a 5.0 cm cavity if not slightly bigger extending posterior from the excision. I did discuss options with the patient including continuing with packing changes. Currently this is significantly better but because of the large size of the cavity, I did recommend that we proceed to exploring the wound sterilely and place a drain. He was placed in the prone position. Buttock cheeks were spread apart and he was prepped and draped sterilely. Local anesthetic with 1% Lidocaine with epinephrine was injected. The wound was explored and probed and the cavity is somewhat decreased but continues with about 5.0 cm area of open cavity. There is some seropurulent drainage but for the most part this is well drained. I did place a Penrose drain in the cavity directed this posteriorly. This was laid flat and was directed to the distant part of the cavity digitally. Drain was then tacked to the skin with #2 nylon sutures. Sterile dressing was placed.
Would you consider this all part of the original global package?