SurgicalAssociates
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I am questioning the correct coding of the following operative report:
Procedure Performed: 1. Removal of infected umbilical mesh
2. Re-closure of fascial defect and removal of sinus tract
3. Removal of umbilical stalk
"A midline elliptical incision was made around her previous hernia site and umbilicus. The skin was then excised and the umbilical stalk was removed. I was able to identify the sinus tract which has some purulent material in it. This was traced down to the mesh and excised. The mesh was then excised from the underlying fascia. The sutures were clipped and adhesions to the mesh were taken down. There was adhesions of omentum to the undersurface of the mesh and these were freed up with cautery as well. An entire circular piece of mesh was removed, it appeared to be 6 to 8 cm in size of diameter. Once completely removed, the wound was irrigated and the wound was closed primarily with double stranded 0 Maxon suture, reapproximating the fascia, enclosing the fascial defect primarily. The skin was then stapled in the midline. The patient tolerated the procedure well and there were no complications"
Any help would be appreciated!!
Procedure Performed: 1. Removal of infected umbilical mesh
2. Re-closure of fascial defect and removal of sinus tract
3. Removal of umbilical stalk
"A midline elliptical incision was made around her previous hernia site and umbilicus. The skin was then excised and the umbilical stalk was removed. I was able to identify the sinus tract which has some purulent material in it. This was traced down to the mesh and excised. The mesh was then excised from the underlying fascia. The sutures were clipped and adhesions to the mesh were taken down. There was adhesions of omentum to the undersurface of the mesh and these were freed up with cautery as well. An entire circular piece of mesh was removed, it appeared to be 6 to 8 cm in size of diameter. Once completely removed, the wound was irrigated and the wound was closed primarily with double stranded 0 Maxon suture, reapproximating the fascia, enclosing the fascial defect primarily. The skin was then stapled in the midline. The patient tolerated the procedure well and there were no complications"
Any help would be appreciated!!