HKOFOID
Networker
Any CPT ideas on this one would be appreciated. My doctor is saying debridement of presacral and perineal wound, debridement of lower quadrant sinus tract with placement of penrose drains. I am not seeing any actual debridement done and can't come up with any codes for this one..
DESCRIPTION OF PROCEDURE: The patient was given general anesthetic. He was placed in Allen stirrups, prepped with Betadine solution and sterile towels. We probed the left lower quadrant site, passed a forceps and found that it seemed to go quite deep towards the pelvis, so I irrigated with saline solution and found that it did in fact tract and drained out through the rectum.
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I then used a curette to clean out as much as possible this sinus tract and then from below probed through the anus cleaning out the sinus tract above the rectum was opened and then cleaned out with a curette the sinus tract where the Penrose exit just lateral to the anus on the right hand side. Finally, the vascular clamp passed to have his drain through the left lower quadrant wound and brought it out to the apex of the rectum and brought outside the anus and then I sutured that drained to preexisting drain that went into the rectum and came out lateral to the rectum. I then cut the looped drain and pulled it through so that the drain now came out via the perineal opening and no longer leaking out to the anus. Finally, I made a second incision just anterior to the sphincter on the right-hand side and made a second incision through there and tunneled the drain, so it went from left lower quadrant out to wound just anterior to the scrotum. Each were sutured in place with nylon. Dry dressings were applied. Dr. XXXX examined the patient and confirmed proper positioning of the drains. He was taken to recovery.
DESCRIPTION OF PROCEDURE: The patient was given general anesthetic. He was placed in Allen stirrups, prepped with Betadine solution and sterile towels. We probed the left lower quadrant site, passed a forceps and found that it seemed to go quite deep towards the pelvis, so I irrigated with saline solution and found that it did in fact tract and drained out through the rectum.
*
I then used a curette to clean out as much as possible this sinus tract and then from below probed through the anus cleaning out the sinus tract above the rectum was opened and then cleaned out with a curette the sinus tract where the Penrose exit just lateral to the anus on the right hand side. Finally, the vascular clamp passed to have his drain through the left lower quadrant wound and brought it out to the apex of the rectum and brought outside the anus and then I sutured that drained to preexisting drain that went into the rectum and came out lateral to the rectum. I then cut the looped drain and pulled it through so that the drain now came out via the perineal opening and no longer leaking out to the anus. Finally, I made a second incision just anterior to the sphincter on the right-hand side and made a second incision through there and tunneled the drain, so it went from left lower quadrant out to wound just anterior to the scrotum. Each were sutured in place with nylon. Dry dressings were applied. Dr. XXXX examined the patient and confirmed proper positioning of the drains. He was taken to recovery.