Good morning,
I need help coding this op report.
Operation: After successful general anesthesia, the patient was prepped in the usual sterile manner with the penile region exposed. He was prepped with chlorhexidine as he is questionable allergic to iodine. The base of the penis was infiltrated with 10 ml of local anesthesia which consisted of equal parts of 1% Xlocaine and 0.5% Marcaine. A circumferential incision was made approximately 1 cm proximal to the edge of the glans penis. Immediately after going through the skin layer there was hematoma evident circumferentially. Using careful dissection using cautery and sharp dissection, the penile skin was degloved. A large amount of clot was extruded once we got into the proper layer. When the penis was degloved to the base of the penis, there was a fracture defect on the right side towards the base of the penis. This was explored manually and the edges were debrided using a metzenbaum scissors. The area was irrigated with warm sterile saline. The edges were also re-approximated with 3-0 vicryl simple sutures. The wound was then again irrigated with sterile saline. The cut eges of the skin were re-approximated with interrupted sutures of 3-0 chromic. Bacitracin was applied to the skin incision. The penis was tightly wrapped with Kerlix. There was hemostatis. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
I don't think that 54440 Plastic operation of penis for injury applies here because the op report does not state that this was a complex repair or closure, and the debridement was not extensive.
I am leaning towards using an unlisted code, but wondered if anyone else has had experience with this type of fracture care
Thank you for your help
Kathleen
I need help coding this op report.
Operation: After successful general anesthesia, the patient was prepped in the usual sterile manner with the penile region exposed. He was prepped with chlorhexidine as he is questionable allergic to iodine. The base of the penis was infiltrated with 10 ml of local anesthesia which consisted of equal parts of 1% Xlocaine and 0.5% Marcaine. A circumferential incision was made approximately 1 cm proximal to the edge of the glans penis. Immediately after going through the skin layer there was hematoma evident circumferentially. Using careful dissection using cautery and sharp dissection, the penile skin was degloved. A large amount of clot was extruded once we got into the proper layer. When the penis was degloved to the base of the penis, there was a fracture defect on the right side towards the base of the penis. This was explored manually and the edges were debrided using a metzenbaum scissors. The area was irrigated with warm sterile saline. The edges were also re-approximated with 3-0 vicryl simple sutures. The wound was then again irrigated with sterile saline. The cut eges of the skin were re-approximated with interrupted sutures of 3-0 chromic. Bacitracin was applied to the skin incision. The penis was tightly wrapped with Kerlix. There was hemostatis. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
I don't think that 54440 Plastic operation of penis for injury applies here because the op report does not state that this was a complex repair or closure, and the debridement was not extensive.
I am leaning towards using an unlisted code, but wondered if anyone else has had experience with this type of fracture care
Thank you for your help
Kathleen