Wiki 15002? 13160? 49585?

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MELJNBBRB

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Hi list,
I am needing some input please on how others would code. I have 15002? 13160? 49585?

TIA,
Melissa Bedford,CCS,CPC



PREOPERATIVE DIAGNOSIS(ES):
1. Intense abdominal wall scar.
2. Necrotic umbilicus.
3. Umbilical hernia.


POSTOPERATIVE DIAGNOSIS(ES):
1. Intense abdominal wall scar.
2. Necrotic umbilicus.
3. Umbilical hernia.


PROCEDURES:
1. Abdominal wall scar excision to include hypertrophic
scarring areas.
2. Excision of umbilicus down to level of fascia 3 x 3 x 4.
3. Repair of umbilical hernia without mesh.


ANESTHESIA:
GETA.


ESTIMATED BLOOD LOSS:
Minimal.


IV FLUIDS:
800.


URINE OUTPUT:
Not recorded.


SPECIMENS TO LAB:
Include,
1. Abdominal wall scar.
2. Umbilicus and stalk.


INDICATIONS FOR OPERATION:
The patient is a 74-year-old female who underwent a
paraesophageal hernia repair and splenectomy and at the same time
was diagnosed with amyloid disease based on her splenectomy
results. She then underwent an incisional hernia repair with
mesh. During the entire time of her healing from her original
operation, she had problems at her umbilical port site. She had
had a previous abdominoplasty in the past and her amyloid disease
does not heal well. Eventually, her umbilicus necrosed and after
multiple attempts at a variety of wound care options, she has
decided to have it excised. She would also like to have her scar
excised as well, and there is a large hypertrophic scar from a
hand port site, which was the extraction point for the spleen.
We discussed the risks and benefits of surgery, and she agreed to
proceed.


PROCEDURE IN DETAIL:
The patient was taken to the operating room, placed supine on the
operating table, and after adequate general endotracheal
anesthesia was given, she was prepped and draped in usual
fashion. The upper midline abdominal wall scar was excised
first. This was done all with sharp dissection and then closed
using a 4-0 Monocryl. Attention was then turned to the
umbilicus, and this was cut out in its entirety, with also using
sharp dissection only to maintain the vascular supply. This was
taken all the way down to the level of fascia where there was a
noted umbilical hernia. The stalk was amputated and sent to
Pathology. The umbilical hernia was repaired with a #1 Tycron in
a figure-of-eight fashion. The wound was irrigated liberally.
The soft tissues and deep tissues were closed using 3-0 Vicryl in
an interrupted fashion. Then, the skin was closed using 4-0
Monocryl in a running fashion, and then all wounds were protected
with Dermabond. The patient tolerated the procedure well, was
extubated at the end of the case, was taken to PACU
 
Here is the H/P

Chief Complaint/Reason for Consult:
Chief Complaint
Patient presents with
? Post-op Exam





HPI: Patient is a 74 y.o. female presents with 10 months status post left upper paraesophageal hernia repair as well as splenectomy. Patient's done well from her paraesophageal hernia repair, her splenectomy revealed a pathology of amyloid for which she has been treated and is doing well. Unfortunately her umbilicus where we had placed were the trochars has had multiple issues likely stemming from a previous abdominoplasty. Her neo-umbilicus has never completely healed and her vascular supply seems to be incapable of healing it completely. She is here to discuss excision.


Past Medical History:
Past Medical History
Diagnosis Date
? Hypertension
? Depression
? Asthma
? PONV (postoperative nausea and vomiting)
? Hyperlipidemia
? Obesity




Past Surgical History:
Past Surgical History
Procedure Laterality Date
? Cosmetic surgery
abdominoplasty
? Tubal ligation
? Joint replacement 2009
rt knee
? Ankle surgery Left
x5




Home Medications:
Current Outpatient Prescriptions
Medication Sig Dispense Refill
? atenolol (TENORMIN) 50 MG tablet Take 50 mg by mouth daily.
? atorvastatin (LIPITOR) 40 MG tablet Take 40 mg by mouth daily.
? beclomethasone (QVAR) 80 mcg/actuation inhaler Inhale 1 puff into the lungs 2 (two) times daily.
? diltiazem (CARDIZEM) 120 MG tablet Take 120 mg by mouth daily.
? DULoxetine (CYMBALTA) 60 MG capsule Take 60 mg by mouth daily.
? estradiol (ESTRACE) 0.01 % (0.1 mg/gram) vaginal cream Place 2 g vaginally daily.
? ipratropium-albuterol (COMBIVENT RESPIMAT) 20-100 mcg/actuation Aero Inhale 1 puff into the lungs every 6 (six) hours.
? methenamine (MANDELAMINE) 1 GM tablet Take 1 g by mouth 2 (two) times daily.
? nitrofurantoin (MACRODANTIN) 100 MG capsule Take 100 mg by mouth 4 (four) times daily.
? solifenacin (VESICARE) 5 MG tablet Take 5 mg by mouth daily.


No current facility-administered medications for this visit.





Allergies:
No Known Allergies


Social History:
History
Substance Use Topics
? Smoking status: Former Smoker
? Smokeless tobacco: Not on file
Comment: smoked in teen years
? Alcohol Use: 3.5 oz/week
7 Glasses of wine per week




Family History:
No family history on file.

Review of Systems:
Denies weakness, fatigue, easy bruising or bleeding, recent unexplained weight loss, chest pain, shortness of breath, and difficulty urinating.


Physical Exam:
Vitals: BP 183/84 | Pulse 68 | Temp(Src) 96.1 ?F (35.6 ?C) | Ht 1.702 m (5' 7") | Wt 101.152 kg (223 lb) | BMI 34.92 kg/m2
General: alert, appears stated age and cooperative. No acute distress.
HEENT: Sclerae anicteric.
Skin: No jaundice, no pallor, no rash.
Neck: Supple.
Lungs: Clear to auscultation bilaterally.
Heart: Regular rate and rhythm.
Abdomen/GU: Chronic granulation tissue with purulence and nonhealing wound
Extremities: No edema.
Neuro: Alert and oriented X 3. Patient is neurovascularly intact.


Diagnostic imaging: None


ASSESSMENT & PLAN:


is a 74 y.o. year old female with nonhealing wound at the umbilicus we discussed the risks and benefits of excision and she has agreed to proceed. Well over half of this visit was spent counseling her and coordinating her repair and care.
 
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