11406?

codedog

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NEW ORLEANS
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need some advice on this one , what would you code ?maybe wound closure ? doesnt giv much info


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POSTOPERATIVE DIAGNOSIS: Nonhealing transverse wound of the mid lower back.
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PROCEDURE: Wide excision of nonhealing transverse wound of the mid lower back,
measuring 17 x 2 cm x 1 cm in gross dimensions.
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monitored anesthesia care with local anesthesia.
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INDICATIONS FOR PROCEDURE: This wound is located in the crease of mid lower back where adipose
tissue comes together forming a crevice. There is induration throughout the
course of this lesion, which measures about 17 cm x 1 cm in width.
PROCEDURE IN DETAIL: Following informed consent, the patient is brought to the
Operating Room side. The back is prepped and draped. A local anesthetic is infiltrated
following institution of monitored anesthesia care. Elliptical incision is
fashioned to completely encompass the nonhealing lesion, which is transverse in
the mid back. Dissection is carried down to a depth of about 1.5 cm into the
area of good tissue. Irrigation with peroxide and antibiotic solution is
followed by a single-layer closure with interrupted 2-0 vertical mattress
sutures. The wound is dressed, and the patient having tolerated the procedure
well, is moved from the Operating Room to Recovery in good condition. All lap,
sponge, instrument, and needle counts are correct. Blood loss is minimal.


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