Lindseywingate1990
Guest
DIAGNOSIS: right axillary hidradenitis with abscess.
PROCEDURE: complex radical excision of right axillary hidradenitis with abscess.
INDICATIONS: painful hidradenitis right axilla with palpable mass in the axilla suspicious for abscess
FINDINGS IN OPERATION: there was a deep abscess extending down into the axillary contents really the chest wall. the area excised was appeoximently 17 cm x 6cm. there was atleast a 4 cm abscess deep in the axilla.
DISCRIPTION OF PROCEDURE: the patient was taken to the operating room, placed in supine position. ..... a bi-elliptical incision was made about the area in question and then excised with palpable and grossly clear margins. gram stain, CNS, fungal stains, and permanent section were sent. the wound was irrigated copiouslywith saline, closed over penrose drain with interrupted 2-0 vicryl sutures and 3-0 nylon horozonal matress sutures and sterile dressing was applied. the patient tolerated the procedure well patient was taken to recovery.
i am thinking a good code would be 21554 for the excision of the deep mass. this is for the chest wall because in the dictation above he says "down into the axillary contents really the chest wall." i am still not sure if this is right does anyone have any input??????
PROCEDURE: complex radical excision of right axillary hidradenitis with abscess.
INDICATIONS: painful hidradenitis right axilla with palpable mass in the axilla suspicious for abscess
FINDINGS IN OPERATION: there was a deep abscess extending down into the axillary contents really the chest wall. the area excised was appeoximently 17 cm x 6cm. there was atleast a 4 cm abscess deep in the axilla.
DISCRIPTION OF PROCEDURE: the patient was taken to the operating room, placed in supine position. ..... a bi-elliptical incision was made about the area in question and then excised with palpable and grossly clear margins. gram stain, CNS, fungal stains, and permanent section were sent. the wound was irrigated copiouslywith saline, closed over penrose drain with interrupted 2-0 vicryl sutures and 3-0 nylon horozonal matress sutures and sterile dressing was applied. the patient tolerated the procedure well patient was taken to recovery.
i am thinking a good code would be 21554 for the excision of the deep mass. this is for the chest wall because in the dictation above he says "down into the axillary contents really the chest wall." i am still not sure if this is right does anyone have any input??????