l1ttle_0ne
Guru
Our doctor did an incision and drainage of a perineal abscess. He says to use 46050 which is a I&D of a perianal abscess. I'm not sure if I agree with this I was thinking it would be a 10060. Can someone please give me their opinion?? Here is the note.
*
PREOP DX: Anal fistula
POSTOP DX: Perineal abscess
*
SURGEON:
**
PROCEDURE: Incision and drainage of perineal abscess.
FINDINGS: There was a hard, thin cord in the subcutaneous tissue 5 cm from the dentate line anteriorly. No obvious external fistula opening. Incision was made over the hard mass and purulent drainage expressed. The cavity was 1 X 2 cm and granulation tissue was curetted.
*
*
OPERATION IN DETAIL: The patient was taken to the operating room and underwent general anesthesia. Patient was sterilely prepped and draped in the high lithotomy position. Perianal block was performed by injecting 10ml local anesthetic in the intersphincteric groove both right and left lateral. *
The mass was palpated. Incision was made over the mass and purulent drainage was expressed. The tract was then followed anterior and posterior. The wound was curetted and hemostasis obtained. Wound was then left open.
Hemostasis was excellent
**
*
PREOP DX: Anal fistula
POSTOP DX: Perineal abscess
*
SURGEON:
**
PROCEDURE: Incision and drainage of perineal abscess.
FINDINGS: There was a hard, thin cord in the subcutaneous tissue 5 cm from the dentate line anteriorly. No obvious external fistula opening. Incision was made over the hard mass and purulent drainage expressed. The cavity was 1 X 2 cm and granulation tissue was curetted.
*
*
OPERATION IN DETAIL: The patient was taken to the operating room and underwent general anesthesia. Patient was sterilely prepped and draped in the high lithotomy position. Perianal block was performed by injecting 10ml local anesthetic in the intersphincteric groove both right and left lateral. *
The mass was palpated. Incision was made over the mass and purulent drainage was expressed. The tract was then followed anterior and posterior. The wound was curetted and hemostasis obtained. Wound was then left open.
Hemostasis was excellent
**
