Please help code this surgery. The doctor wants different codes, but we can't find any other codes that are correct.
Pre-Op Dx
Periumbilical discomfort and drainage
Post-Op Dx
Periumbilical discomfort and drainage
Procedures
1. Abdominal wall exploration
2. Drainage of abdominal wall abscess
3. Removal of old stitch
Findings
The patient had an old transfascial suture with chronic inflammation which was removed. The fascia was not entered.
Detailed Operative Note
After informed consent was obtained from the patient, the patient was taken to the operating room and placed in supine position. After adequate anesthesia was provided, the periumbilical area was shaved, prepped and draped in standard surgical fashion using Prevail. At this time, 1% Lidocaine with Epinephrine was injected at the periumbilical chronic wound area. Using a #15 blade, a small 3-4mm incision was made and a small amount of pus was drained. The wound was irrigated. Further evaluation in this area showed an old Eithibond transfascial suture that seemed to be the source of the problem. This was dissected out, snipped and passed off for permanent pathology. The wound was irrigated. Reevaluation showed no residual problems. Steri-Strips, 2 x 2s and Tegaderm were place.
My administrator and I agree on 10060 and 10121. The doctor wants a code for abdominal exploration. Does anybody have any suggestions.
Thanks in advance!!!
Pre-Op Dx
Periumbilical discomfort and drainage
Post-Op Dx
Periumbilical discomfort and drainage
Procedures
1. Abdominal wall exploration
2. Drainage of abdominal wall abscess
3. Removal of old stitch
Findings
The patient had an old transfascial suture with chronic inflammation which was removed. The fascia was not entered.
Detailed Operative Note
After informed consent was obtained from the patient, the patient was taken to the operating room and placed in supine position. After adequate anesthesia was provided, the periumbilical area was shaved, prepped and draped in standard surgical fashion using Prevail. At this time, 1% Lidocaine with Epinephrine was injected at the periumbilical chronic wound area. Using a #15 blade, a small 3-4mm incision was made and a small amount of pus was drained. The wound was irrigated. Further evaluation in this area showed an old Eithibond transfascial suture that seemed to be the source of the problem. This was dissected out, snipped and passed off for permanent pathology. The wound was irrigated. Reevaluation showed no residual problems. Steri-Strips, 2 x 2s and Tegaderm were place.
My administrator and I agree on 10060 and 10121. The doctor wants a code for abdominal exploration. Does anybody have any suggestions.
Thanks in advance!!!