I could use some help please. The surgeon had to take pt back to surgery 2 hours after orginal surgery. Pt had some excessive post operative drainage.
2nd surgery
POST image guided functional endoscopic sinus surgery and turbinate reduction. OR report reads no evidence of defect in the cribriform plate, lateral or posterior of either sinus surgical site. No evidence of excessive bleeding
Th pt. was checked endoscopically. The fibrillar and the ethmoidectomy defect was vacuumed until clear and removed with forceps. This side was then temporary packed and then the packing removed and patient re-examined. The surgical site was found to be dry.The fibrillar was then repalced. Same thing was done to the other side. I am not sure how to code this. It appears the surgeon didn't find anything wrong. I'm not sure what ICD-9 code or CPT code to use for this. I know I need to use a 78 mod. But am unsure about the other.
Any help you can offer would be great! THanks kdm
2nd surgery
POST image guided functional endoscopic sinus surgery and turbinate reduction. OR report reads no evidence of defect in the cribriform plate, lateral or posterior of either sinus surgical site. No evidence of excessive bleeding
Th pt. was checked endoscopically. The fibrillar and the ethmoidectomy defect was vacuumed until clear and removed with forceps. This side was then temporary packed and then the packing removed and patient re-examined. The surgical site was found to be dry.The fibrillar was then repalced. Same thing was done to the other side. I am not sure how to code this. It appears the surgeon didn't find anything wrong. I'm not sure what ICD-9 code or CPT code to use for this. I know I need to use a 78 mod. But am unsure about the other.
Any help you can offer would be great! THanks kdm