tadailey
Contributor
I'm not 100% sure how to code this. I don't feel documentation covers 11004 since debridement was only superficial but at the same time I don't feel 55100 and 11042 are accurate either. Any suggestions??
Op notes states:
His genitalia was prepped and draped in the standard fashion. Local anesthetic was provided over the right abscess site and necrotic scrotal area to provide good anesthesia. I made an incision directly over the abscessed area. Purulent material was . Only a small amount, buit dead skin and dartos was seen. This was debrided sharply until bleeding. This was all superficial, involving at deepest small layer of Dartos fascia. I cut until bleeding was seen. I carried the incisions to the necrotic scrotal skin. All necrotic areas were removed. This was done sharply and the patient tolerated very well. Following this, approximately 5 cm x 8 cm of skin had been removed and debrided.
I then irrigated this with over a liter of normal saline. The wound did not tract down his buttock or up his groin. The entire cavity was washed thoroughly. There was no further bleeding. Residual tissue looked healthy. I then packed it with 1" idoform and placed 4x4 gauze and mesh panties were placed. Patient tolerated very well.
Thanks
Teresa
Op notes states:
His genitalia was prepped and draped in the standard fashion. Local anesthetic was provided over the right abscess site and necrotic scrotal area to provide good anesthesia. I made an incision directly over the abscessed area. Purulent material was . Only a small amount, buit dead skin and dartos was seen. This was debrided sharply until bleeding. This was all superficial, involving at deepest small layer of Dartos fascia. I cut until bleeding was seen. I carried the incisions to the necrotic scrotal skin. All necrotic areas were removed. This was done sharply and the patient tolerated very well. Following this, approximately 5 cm x 8 cm of skin had been removed and debrided.
I then irrigated this with over a liter of normal saline. The wound did not tract down his buttock or up his groin. The entire cavity was washed thoroughly. There was no further bleeding. Residual tissue looked healthy. I then packed it with 1" idoform and placed 4x4 gauze and mesh panties were placed. Patient tolerated very well.
Thanks
Teresa