hcg
Guru
Can someone please help me with this report. I can't seem to find a specific code for this procedure:
DATE OF OPERATION: 12/2018
PREOPERATIVE DIAGNOSES
1. Pelvic abscess.
2. Sacral osteomyelitis.
POSTOPERATIVE DIAGNOSES
1. Pelvic abscess.
2. Sacral osteomyelitis.
TITLE OF OPERATION
1. Endoscopic drainage of pelvic abscess.
2. Argon ablation of the rectal abscess cavity.
SURGEON
Dr. A
ANESTHESIA
Conscious sedation.
INDICATIONS
A 48-year-old patient who has had laryngeal resection with
mucous fistula. Patient's mucous fistula has broken down, and has had a
fluid collection develop in the sacral area. There was imaging
demonstrating suspicion of osteomyelitis. The patient was surgically
consented for endoscopic drainage of pelvic fluid collection.
DESCRIPTION OF OPERATION
After informed consent was obtained, the patient was taken to the endoscopy
suite. Conscious sedation was administered, and the patient was placed in
the left lateral decubitus position. Digital rectal examination revealed
normal rectal sphincter and a closed mucous defect which had been
previously opened. Scope was then inserted and under direct visualization
the cavity traversed, and entering the presacral fluid collection cultures
were obtained and biopsies were obtained of the bony prominence. These were
submitted for culture and sensitivities to direct antibiotics. Numerous
biopsies were also obtained to submit for histology to rule out recurrent
cancer. The Argon coagulation was then inserted and the defect ablated to
obtain hemostasis. The connection between the rectal stump and the sacral
collection was also ablated to prevent early closure. The patient tolerated
the procedure well.
There are 3 unlisted codes I can think of, code 45999 for the ablation for rectal abscess and 27299 or 49329 for the pelvic abscess. I appreciate every help I can get.
DATE OF OPERATION: 12/2018
PREOPERATIVE DIAGNOSES
1. Pelvic abscess.
2. Sacral osteomyelitis.
POSTOPERATIVE DIAGNOSES
1. Pelvic abscess.
2. Sacral osteomyelitis.
TITLE OF OPERATION
1. Endoscopic drainage of pelvic abscess.
2. Argon ablation of the rectal abscess cavity.
SURGEON
Dr. A
ANESTHESIA
Conscious sedation.
INDICATIONS
A 48-year-old patient who has had laryngeal resection with
mucous fistula. Patient's mucous fistula has broken down, and has had a
fluid collection develop in the sacral area. There was imaging
demonstrating suspicion of osteomyelitis. The patient was surgically
consented for endoscopic drainage of pelvic fluid collection.
DESCRIPTION OF OPERATION
After informed consent was obtained, the patient was taken to the endoscopy
suite. Conscious sedation was administered, and the patient was placed in
the left lateral decubitus position. Digital rectal examination revealed
normal rectal sphincter and a closed mucous defect which had been
previously opened. Scope was then inserted and under direct visualization
the cavity traversed, and entering the presacral fluid collection cultures
were obtained and biopsies were obtained of the bony prominence. These were
submitted for culture and sensitivities to direct antibiotics. Numerous
biopsies were also obtained to submit for histology to rule out recurrent
cancer. The Argon coagulation was then inserted and the defect ablated to
obtain hemostasis. The connection between the rectal stump and the sacral
collection was also ablated to prevent early closure. The patient tolerated
the procedure well.
There are 3 unlisted codes I can think of, code 45999 for the ablation for rectal abscess and 27299 or 49329 for the pelvic abscess. I appreciate every help I can get.