maine4me
Guru
Would someone please look at the attached operative note. This patient was admitted to the hospital and underwent a procedure to draing a sermoa of the left groin, this was completed and the wound was packed with sterile gauze. The following day the patient was fund to have significant bleeding from the wound, and the surgeon call controlled the bleeding. He has reported a 99233 - 24. Since the second surgeon is part of the same surgical practice, this way of coding is not correct. I think there must be a way to code the procedure, but am having trouble determining the correct code. Any help is appreciated.
PREOPERATIVE DIAGNOSIS: Bleeding from left groin wound.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION: Exploration of left groin wound and control of subcutaneous bleeding.
ANESTHESIA: Local.
PROCEDURE AND FINDINGS: The patient had exploration of his groin for seroma and was in
the hospital and was noted to be having a good deal of blood from the left groin. He
remained in his hospital bed and preop diagnosis, procedure and site were confirmed on
time out. The area was cleaned and then the skin edges and subcutaneous tissue around the
circumference was injected with 1% plain Xylocaine. The wound was then explored and
multiple small bleeders were noted in the subcutaneous tissue. These were controlled with
a Vasector. The wound was explored down to the depth and there did not appear to be any
bleeding in the lower region. After fulguration of multiple bleeders, no more active
bleeding was noted. Saline soaked Kerlix was then placed into the depth of the wound and
in the subcutaneous tissue and over this dressings were applied and taped in place. He
tolerated the procedure well.
PREOPERATIVE DIAGNOSIS: Bleeding from left groin wound.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION: Exploration of left groin wound and control of subcutaneous bleeding.
ANESTHESIA: Local.
PROCEDURE AND FINDINGS: The patient had exploration of his groin for seroma and was in
the hospital and was noted to be having a good deal of blood from the left groin. He
remained in his hospital bed and preop diagnosis, procedure and site were confirmed on
time out. The area was cleaned and then the skin edges and subcutaneous tissue around the
circumference was injected with 1% plain Xylocaine. The wound was then explored and
multiple small bleeders were noted in the subcutaneous tissue. These were controlled with
a Vasector. The wound was explored down to the depth and there did not appear to be any
bleeding in the lower region. After fulguration of multiple bleeders, no more active
bleeding was noted. Saline soaked Kerlix was then placed into the depth of the wound and
in the subcutaneous tissue and over this dressings were applied and taped in place. He
tolerated the procedure well.