I was thinking cpt code 49020 and 11005. I co worker says 49020 and 11008 along with 11005. Can someone help with the correct coding of this
OPERATIVE REPORT
DATE OF OPERATION: 08/09/2016
SURGEON: Doctor A
PREOPERATIVE DIAGNOSIS: Abdominal abscess.
POSTOPERATIVE DIAGNOSES:
1. Intraabdominal abscess.
2. Infected prosthetic mesh abdominal wall.
PROCEDURE PERFORMED:
1. Abdominal wound exploration.
2. Drainage of intraabdominal abscess.
3. Removal of infected mesh.
ASSISTANT: Doctor B
ANESTHESIA: Monitored anesthesia care with local. A total of
10 mL of 0.5% Marcaine with epinephrine was given.
COMPLICATIONS: None.
FINDINGS: There was approximately a 1 cm deep x 6 cm x 4 cm abscess area located deep to the muscle layer. Within this muscle layer, there was a portion of the previously used 20 cm biologic mesh which was free-floating which was easily removed with simple debridement. There is no evidence of any enteric drainage. The fluid was not foul-smelling. It was sent for culture.
COMPLICATIONS: None.
DISPOSITION: Stable to recovery room.
HISTORY: This is a 64-year-old gentleman who has returned to the operating room after an exploration yesterday did not yield a finding of infection which was seen on previous CT scan. A drainage catheter was left within the abdomen within the deepest plane I accessed. On CT scan this morning, the infected fluid cavity was approximately 0.5 cm deep to the tip of the drainage catheter without any nearby bowel. The patient is, therefore, brought back to the operating room for
opening up of this posterior layer and drainage of abscess.
REPORT OF OPERATION: After consent was obtained, the patient was brought back to the operating room. He was placed supine on the operating table. He was given monitored anesthesia care. The left lower quadrant ileostomy was sutured closed with 0 silk suture. The abdomen was prepped with Betadine. Due to the recent open wound, the abdomen was dressed sterilely and the ostomy was secured from the wound using a 4 x 4 and Ioban. Prior to incision, a time-out was performed confirming correct patient name, procedure and procedure site. All team members agreed. To begin, the staples were removed from the midline wound.
The wound was opened up. The Maxon sutures which were encountered were removed from the previous layer. The fascial layer was identified again, and below this, it was noted there was a thin layer likely of thickened peritoneum which was identified. This area was incised, which was just deep to the catheter
tip towards the right side of the midline. Gaining access into this space with a small incision yielded creamy fluid which was sent for culture. It was rather whitish, and did not have a foul smell. Exploration of the wound digitally broke up all loculations. It was noted that there was some biologic mesh floating
within this cavity. It was grasped with hemostats and parts of it were pulled out that were not incorporated in the fascia. This was sent for pathology.
The wound was copiously irrigated out with normal saline and suctioned out. A new 15-French Blake drain was tunneled through the previous stab incision down deeper into the abdominal wall and brought into the preperitoneal plane, and the catheter remained in place. There is no evidence of any enteric drainage or stool.
The drain was sutured to the skin using a 2-0 nylon suture. The deep fascial layer was closed with a running 0 Maxon suture. The biologic mesh onlay was closed with a running 2-0 Prolene suture. The wound was irrigated out and closed with staples. A small Telfa wick was placed in the inferior edge of the wound. The areas dressed with gauze and tape. At the end of the procedure, the Ioban was removed. The leostomy in the left lower quadrant was redressed with stoma appliance. There were no complications. The patient was awakened and transferred to the recovery room in stable condition. Sponge and instrument counts were correct.
OPERATIVE REPORT
DATE OF OPERATION: 08/09/2016
SURGEON: Doctor A
PREOPERATIVE DIAGNOSIS: Abdominal abscess.
POSTOPERATIVE DIAGNOSES:
1. Intraabdominal abscess.
2. Infected prosthetic mesh abdominal wall.
PROCEDURE PERFORMED:
1. Abdominal wound exploration.
2. Drainage of intraabdominal abscess.
3. Removal of infected mesh.
ASSISTANT: Doctor B
ANESTHESIA: Monitored anesthesia care with local. A total of
10 mL of 0.5% Marcaine with epinephrine was given.
COMPLICATIONS: None.
FINDINGS: There was approximately a 1 cm deep x 6 cm x 4 cm abscess area located deep to the muscle layer. Within this muscle layer, there was a portion of the previously used 20 cm biologic mesh which was free-floating which was easily removed with simple debridement. There is no evidence of any enteric drainage. The fluid was not foul-smelling. It was sent for culture.
COMPLICATIONS: None.
DISPOSITION: Stable to recovery room.
HISTORY: This is a 64-year-old gentleman who has returned to the operating room after an exploration yesterday did not yield a finding of infection which was seen on previous CT scan. A drainage catheter was left within the abdomen within the deepest plane I accessed. On CT scan this morning, the infected fluid cavity was approximately 0.5 cm deep to the tip of the drainage catheter without any nearby bowel. The patient is, therefore, brought back to the operating room for
opening up of this posterior layer and drainage of abscess.
REPORT OF OPERATION: After consent was obtained, the patient was brought back to the operating room. He was placed supine on the operating table. He was given monitored anesthesia care. The left lower quadrant ileostomy was sutured closed with 0 silk suture. The abdomen was prepped with Betadine. Due to the recent open wound, the abdomen was dressed sterilely and the ostomy was secured from the wound using a 4 x 4 and Ioban. Prior to incision, a time-out was performed confirming correct patient name, procedure and procedure site. All team members agreed. To begin, the staples were removed from the midline wound.
The wound was opened up. The Maxon sutures which were encountered were removed from the previous layer. The fascial layer was identified again, and below this, it was noted there was a thin layer likely of thickened peritoneum which was identified. This area was incised, which was just deep to the catheter
tip towards the right side of the midline. Gaining access into this space with a small incision yielded creamy fluid which was sent for culture. It was rather whitish, and did not have a foul smell. Exploration of the wound digitally broke up all loculations. It was noted that there was some biologic mesh floating
within this cavity. It was grasped with hemostats and parts of it were pulled out that were not incorporated in the fascia. This was sent for pathology.
The wound was copiously irrigated out with normal saline and suctioned out. A new 15-French Blake drain was tunneled through the previous stab incision down deeper into the abdominal wall and brought into the preperitoneal plane, and the catheter remained in place. There is no evidence of any enteric drainage or stool.
The drain was sutured to the skin using a 2-0 nylon suture. The deep fascial layer was closed with a running 0 Maxon suture. The biologic mesh onlay was closed with a running 2-0 Prolene suture. The wound was irrigated out and closed with staples. A small Telfa wick was placed in the inferior edge of the wound. The areas dressed with gauze and tape. At the end of the procedure, the Ioban was removed. The leostomy in the left lower quadrant was redressed with stoma appliance. There were no complications. The patient was awakened and transferred to the recovery room in stable condition. Sponge and instrument counts were correct.