along501
Contributor
- Messages
- 19
- Location
- Lake Charles, LA
I have been going back and forth with this operative on the codes for this case. Help me see what I could be missing.
22015-I&D open deep lumbar
OR
10140- I&D of seroma or fluid collection
OR
22830 -exploration of spinal fusion
10140- I&D of seroma or fluid collection
Please help! Patient is in a global surgery from prior lumbar fusion.
Procedure right sided Metrix wound exploration evacuation of fluid collection. Wound revision.
IntraOp use of microscope for microdissection fluoroscopy for localization.
Anesthesia General Tracheal and local estimated blood loss minimal
Drain 10 french
Specimen none
Findings no convincing evidence of CSF leak with multiple Valsalva's and tube positioning's. This was also explored open with the cerebellar and Valsalva multiple times. The tissue was very friable consistent with a recent amount of weight loss. The fluid itself was most consistent with seroma. The
Indications for procedure this pleasant 69-year-old female status post transforaminal lumbar interbody fusion with resolution of radiculopathy. The patient had a fluid collection that was initially small underneath the right incision that had grown quite large it was not under pressure was quite ballotable. She did not have any significant headaches. This was drained in the office and cultured with negative results. It did recur and was causing discomfort. The risk benefits and alternatives to exploration were discussed in detail the patient was in agreement and wished to proceed.
Prescription of operative procedure after confirming site side level patient in procedure she was taken to the operative theater where after sufficient general endotracheal anesthesia was induced a timeout was completed and preoperative antibiotics were given. Patient was placed in the prone position on the operating room table all pressure points joints padded appropriately the previous incision was demarcated on the right there was a ballotable fluid collection. This was infiltrated and incised deep dermal dissection was carried out the monopolar electrocautery through the well-healed wound into the fluid collection which was under a small amount of pressure and was proteinaceous and bloody. This was evacuated at which time tubular tractor was placed down to the L4-5 level additional soft tissue and scar was clear the area was taken down to the dura and the nerve root in the foramen and the area inspected thoroughly with multiple Valsalva as no CSF leakage was noted. There was a chronic tissue oozing circumferentially as well as the muscle. There was brought in the hemostasis and inspected again it was again Valsalva multiple times at which time was brought on hemostasis with Surgiflo and washed with vancomycin tenting lactated ringer. Small pieces of Gelfoam were placed as well as DuraGen around the rod and pushed down around the screws was then sealed with adherence in an over abundance of caution. The muscle and surrounding weepy soft tissue was brought under hemostasis and coagulated with Lachman's and bipolar electrocautery the wound was then dusted with Surgicel snow and vancomycin powder. A 10 French was placed prior to watertight fascial closure with 0 Ethibond sutures. The deep dermal region was then closed using simple interrupted inverted 2-0 Vicryl sutures deep dermal closure and a running locking nylon for skin closure.
22015-I&D open deep lumbar
OR
10140- I&D of seroma or fluid collection
OR
22830 -exploration of spinal fusion
10140- I&D of seroma or fluid collection
Please help! Patient is in a global surgery from prior lumbar fusion.
Procedure right sided Metrix wound exploration evacuation of fluid collection. Wound revision.
IntraOp use of microscope for microdissection fluoroscopy for localization.
Anesthesia General Tracheal and local estimated blood loss minimal
Drain 10 french
Specimen none
Findings no convincing evidence of CSF leak with multiple Valsalva's and tube positioning's. This was also explored open with the cerebellar and Valsalva multiple times. The tissue was very friable consistent with a recent amount of weight loss. The fluid itself was most consistent with seroma. The
Indications for procedure this pleasant 69-year-old female status post transforaminal lumbar interbody fusion with resolution of radiculopathy. The patient had a fluid collection that was initially small underneath the right incision that had grown quite large it was not under pressure was quite ballotable. She did not have any significant headaches. This was drained in the office and cultured with negative results. It did recur and was causing discomfort. The risk benefits and alternatives to exploration were discussed in detail the patient was in agreement and wished to proceed.
Prescription of operative procedure after confirming site side level patient in procedure she was taken to the operative theater where after sufficient general endotracheal anesthesia was induced a timeout was completed and preoperative antibiotics were given. Patient was placed in the prone position on the operating room table all pressure points joints padded appropriately the previous incision was demarcated on the right there was a ballotable fluid collection. This was infiltrated and incised deep dermal dissection was carried out the monopolar electrocautery through the well-healed wound into the fluid collection which was under a small amount of pressure and was proteinaceous and bloody. This was evacuated at which time tubular tractor was placed down to the L4-5 level additional soft tissue and scar was clear the area was taken down to the dura and the nerve root in the foramen and the area inspected thoroughly with multiple Valsalva as no CSF leakage was noted. There was a chronic tissue oozing circumferentially as well as the muscle. There was brought in the hemostasis and inspected again it was again Valsalva multiple times at which time was brought on hemostasis with Surgiflo and washed with vancomycin tenting lactated ringer. Small pieces of Gelfoam were placed as well as DuraGen around the rod and pushed down around the screws was then sealed with adherence in an over abundance of caution. The muscle and surrounding weepy soft tissue was brought under hemostasis and coagulated with Lachman's and bipolar electrocautery the wound was then dusted with Surgicel snow and vancomycin powder. A 10 French was placed prior to watertight fascial closure with 0 Ethibond sutures. The deep dermal region was then closed using simple interrupted inverted 2-0 Vicryl sutures deep dermal closure and a running locking nylon for skin closure.