jennie_land
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My Doc did an I&D of a vaginal cuff abscess. The abscess was a post op complication of a TLH done last month. The op note list the DX as post op pelvic abscess. However this is what the op note saids:
Examination under anesthesia revealed induration at the vaginal cuff and fullness. The weighted speculum was placed into the Vagina and with the aid of a sims retractor, the anterior vaginal cuff was grasped with Allis clamp; posterior lip likewise grasped, and moderate traction resulted in division of the the cuff with return of purulent liquid of approximately 25-30 ml. This was cultured for both aerobic and anaerobic bacteria and then explored using the sucker tip with return of further liquid. When no further liquid returned and it was obvious that further loculations could be broken up, the Allis clamps were removed. Minimal bleeding being noted, ther procedure was terminated.
How should I code this?
Thanks!
Examination under anesthesia revealed induration at the vaginal cuff and fullness. The weighted speculum was placed into the Vagina and with the aid of a sims retractor, the anterior vaginal cuff was grasped with Allis clamp; posterior lip likewise grasped, and moderate traction resulted in division of the the cuff with return of purulent liquid of approximately 25-30 ml. This was cultured for both aerobic and anaerobic bacteria and then explored using the sucker tip with return of further liquid. When no further liquid returned and it was obvious that further loculations could be broken up, the Allis clamps were removed. Minimal bleeding being noted, ther procedure was terminated.
How should I code this?
Thanks!