AimeeNK31
New
I am trying to figure out if there is indeed a code for this that I am missing or if I need to use an unlisted code. I would also like verification that using 13101 for the scar revision is correct. Thanks in advance.
Pre-Op Diagnosis: Non-healing surgical wound [998.83]
Post-Op Diagnosis: same
Procedures Performed (detailed):Excision of fistulous opening, scar revision, cauterization of seroma cavity and placement of fibrin glue
Type of Anesthesia:General
Procedure Findings:The seroma cavity underneath the skin opening measured about 3 cm.
Procedure Description:
The patient was identified in the holding area, the consent was reviewed with the patient and the right side was marked. The indication for this procedure is a non-healing wound with a fistulous opening from a seroma cavity in the mastectomy site of the right breast. The patient was taken to the OR and placed on the table in supine position. Then under general anesthesia, the right chest was prepped and draped in the usual sterile fashion. Using a 15 blade, an elliptical incision was made to excise the fistulous opening. Underneath was noted to be about a 3 cm seroma cavity that continues to secrete fluid. The surface was then cauterized and the space irrigated with sterile water. Then 10 cc of fibrin glue was injected into the cavity. Then the skin edges were re-approximated and closed externally with 3-0 nylon sutures. The incision was dressed with Xeroform gauze, fluffs and ABD pad. 0.25% marcaine was injected as local anesthesia. All counts were correct at the end of the case and the patient was extubated and sent to recovery in stable condition.
Complications: none
Implants/Grafts/Tissues/Prosthetic Devices/Screws/Pins:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No. Used Action
TISSUE TISSEEL FROZEN 10ML KIT FIBRIN SEALANT HUMAN 1501263 - LOG135868 GENERAL TISSUE TISSEEL FROZEN 10ML KIT FIBRIN SEALANT HUMAN 1501263 BAXTER HEALTHCARE VND4N104 Right 1 Implanted
Pre-Op Diagnosis: Non-healing surgical wound [998.83]
Post-Op Diagnosis: same
Procedures Performed (detailed):Excision of fistulous opening, scar revision, cauterization of seroma cavity and placement of fibrin glue
Type of Anesthesia:General
Procedure Findings:The seroma cavity underneath the skin opening measured about 3 cm.
Procedure Description:
The patient was identified in the holding area, the consent was reviewed with the patient and the right side was marked. The indication for this procedure is a non-healing wound with a fistulous opening from a seroma cavity in the mastectomy site of the right breast. The patient was taken to the OR and placed on the table in supine position. Then under general anesthesia, the right chest was prepped and draped in the usual sterile fashion. Using a 15 blade, an elliptical incision was made to excise the fistulous opening. Underneath was noted to be about a 3 cm seroma cavity that continues to secrete fluid. The surface was then cauterized and the space irrigated with sterile water. Then 10 cc of fibrin glue was injected into the cavity. Then the skin edges were re-approximated and closed externally with 3-0 nylon sutures. The incision was dressed with Xeroform gauze, fluffs and ABD pad. 0.25% marcaine was injected as local anesthesia. All counts were correct at the end of the case and the patient was extubated and sent to recovery in stable condition.
Complications: none
Implants/Grafts/Tissues/Prosthetic Devices/Screws/Pins:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No. Used Action
TISSUE TISSEEL FROZEN 10ML KIT FIBRIN SEALANT HUMAN 1501263 - LOG135868 GENERAL TISSUE TISSEEL FROZEN 10ML KIT FIBRIN SEALANT HUMAN 1501263 BAXTER HEALTHCARE VND4N104 Right 1 Implanted