sheena91382
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My doc is wanting me to code this as a breast fistulotomy & I'm unsure which code I need to use.
The op note is as follows:
Pre-Op Dx: right breast recurrent abscess
Post-Op Dx: right breast recurrent abscess
Operation: I&D right breast abscess with fistulectomy
Anesthesia: Local w/ IV sedation
Procedure: The patient had pre-marked the area in question. She then was brought into the operating room where she underwent IV sedation, was prepped with Chloraprep and draped in the usual sterile fashion. An appropriate time-out was held. The skin and subcutaneous tissues at the 12 o'clock position of the nipple were anesthetized. I first excised the granulation tissue of the abscess. I then followed from the nipple out through this area of the abscess with a lacrimal proble. I filleted open sharply the tissue above the lacrimal probe removing just a very small strip. This was cored out. I placed three Prolene sutures through the nipple and then packed the area above the nipple with a moist two x two and dressing was placed. The patient tolerated the procedure well, was taken back to her room for discharge later same day. All counts correct at the end case. Estimmated blood loss was minimal. No pathology is pending.