I have had several opinions on this topic. How about another one? Please advise what CPT code would be appropriate for the below OP note?
The patient was brought to the preoperative holding area. She was then transferred to the operating room and placed on the operating table in a prone position. We then performed a local block in the posterior left lower leg surrounding the open area at the suture granuloma site with approximately 5 mL of 0.5% Marcaine with epinephrine 1:400,000. The left lower extremity was then prepped with Hibiclens and draped in the usual sterile manner. Attention was directed first to the left lower leg where an approximate 2.5-cm incision was placed at the posterior central left lower leg at the former incision site for the tendo-Achilles repair. The granuloma opening was lateral to the incision. We found a granuloma surrounding the suture. The suture was removed in toto approximately 2.5 inches. The area was irrigated with copious amounts of normal saline. The skin was closed with horizontal mattress sutures of 4-0 nylon
The patient was brought to the preoperative holding area. She was then transferred to the operating room and placed on the operating table in a prone position. We then performed a local block in the posterior left lower leg surrounding the open area at the suture granuloma site with approximately 5 mL of 0.5% Marcaine with epinephrine 1:400,000. The left lower extremity was then prepped with Hibiclens and draped in the usual sterile manner. Attention was directed first to the left lower leg where an approximate 2.5-cm incision was placed at the posterior central left lower leg at the former incision site for the tendo-Achilles repair. The granuloma opening was lateral to the incision. We found a granuloma surrounding the suture. The suture was removed in toto approximately 2.5 inches. The area was irrigated with copious amounts of normal saline. The skin was closed with horizontal mattress sutures of 4-0 nylon