I need help determining a code for the following procedure:
INDICATIONS FOR PROCEDURE: The patient is a 58 yr old male who underwent a left total hip arthroplasty revision 9 days ago. The patient presented to the office yesterday w/ copious serosanguineous dark bloody drainage from his hip. There was no surrounding erythema or induration. The patient has been afebrile. His white count was normal. His CRP was mildly elevated at just over 5. However, clinically w/ a copious drainage, he had the appearance of an early postoperative infection. Therefore, immediate irrigation and debridement of the wound was recommended to try and retain the existing components.
OPERATIVE TECHNIQUE: The old incision was opened. There was probably 500 milliliters of fluid w/in the hip that was removed. Cultures were taken and sent for aerobic, anaerobic cultures in triplicate. The wound was then opened up all the way down to the joint and copious irrigation using a total of 9 liters antibiotic containing saline solutin using the pulse lavage was then used to really wash out the wound. The surfaces were washed w/ digital massage.
I'm not sure wether it fits CPT 10180 or 27030. I also did not see any documentation of debridement, just irrigation. Please help.
INDICATIONS FOR PROCEDURE: The patient is a 58 yr old male who underwent a left total hip arthroplasty revision 9 days ago. The patient presented to the office yesterday w/ copious serosanguineous dark bloody drainage from his hip. There was no surrounding erythema or induration. The patient has been afebrile. His white count was normal. His CRP was mildly elevated at just over 5. However, clinically w/ a copious drainage, he had the appearance of an early postoperative infection. Therefore, immediate irrigation and debridement of the wound was recommended to try and retain the existing components.
OPERATIVE TECHNIQUE: The old incision was opened. There was probably 500 milliliters of fluid w/in the hip that was removed. Cultures were taken and sent for aerobic, anaerobic cultures in triplicate. The wound was then opened up all the way down to the joint and copious irrigation using a total of 9 liters antibiotic containing saline solutin using the pulse lavage was then used to really wash out the wound. The surfaces were washed w/ digital massage.
I'm not sure wether it fits CPT 10180 or 27030. I also did not see any documentation of debridement, just irrigation. Please help.
