jason.lang
Contributor
Please help, coding scenario conundrum.
It's been suggested 11772 - Excision of pilonidal cyst or sinus; complicated
OPERATIVE REPORT (PRIMARY SURGEON)
PREOPERATIVE DIAGNOSIS: Complex pilonidal cyst tracts with fistulae, chronic
actinomyces infection.
POSTOPERATIVE DIAGNOSIS: Complex pilonidal cyst tracts with fistulae, chronic
actinomyces infection.
PROCEDURE: Excision of complex pilonidal cyst disease with perianal fistulas,
excision size of 12 x 9 x 2 cm.
ANESTHESIA: General endotracheal anesthesia with 30 mLs of 0.25% plain Marcaine.
INTRAOPERATIVE FINDINGS:
1. Numerous fistulous draining tracts with granulation tissue underneath,
consistent with tracking pilonidal disease.
2. No perianal or rectal involvement of the process over the coccyx.
3. Muscle over the tip of the coccyx was viable and healthy.
4. On anoscopy, the anal mucosa appeared normal up to approximately 5 cm.
Digital rectal exam revealed normal tone.
15-year-old male who has had a nearly
8-month struggle with persistently draining perianal fistulae. These continued
to drain and were treated with numerous courses of antibiotics after initial
admission to the SIU Pediatric Hospitalist Service approximately 8 months ago.
He has had an extensive workup by the pediatric GI service and Crohn's disease
was ruled out. The patient had MRI studies, which revealed inflammation around
the tip of the coccyx and these complex fistulae involving the perianal skin,
but not involving the rectum. Due to the chronicity of the complex fistula
which grew actinomyces and has persistently grown this organism, a referral to
Dr. Paul Pacheco, Springfield Clinic Colorectal Specialist, was undertaken. He
was evaluated in Dr. Pacheco's clinic and scheduled today for a joint complex
excision of the involved tissues in hopes of healing totally by secondary
intention with the SIU Pediatric Surgery Service. The patient's mother provided
written surgical consent for excision of complex pilonidal cyst disease with
perianal fistulae under general anesthesia after she was made aware of the
possible complications of surgery, which may include but are not limited to:
Death, pain, bleeding, infection, possible hypertrophic scarring, possible
keloid formation, possible damage to the sphincters, possible damage to the
rectum and anus, possible need for wound VAC therapy, possible need for complex
flap closures, possible need for reexcisions in the future, possible need for
perioperative blood product administration and/or antibiotic therapy, possible
need for prolonged hospitalization, and consent was obtained.
DESCRIPTION OF PROCEDURE: Jveon was transported to the operating room. He was
positioned onto the operative table in the supine position after informed
consent was obtained. After adequate IV sedation and general endotracheal
anesthesia were administered, the patient was repositioned onto the operative
bed in the prone position. The patient's face, ET tube and extremities were all
padded and supported per HSHS OR protocol. Tape was used to spread the
patient's gluteal cheeks laterally. The patient's perianal skin was prepped and
draped in the usual sterile fashion using Betadine paint. A timeout procedure
was undertaken to correctly identify the patient, to verify his positioning onto
the operative table in the above-named position, and to verify the procedure to
be performed. All staff members present were in agreement on all accounts.
Attention was directed to the perianal skin, where 3 distinct draining fistula
sites with associated granulation tissue were noted. A digital rectal
examination was performed and revealed normal sphincter tone. Anoscopy was
performed with an anoscope, revealing normal rectal mucosa up to 5 cm with no
connecting fistulae. Probes were placed through the perianal skin fistula site
and these revealed that the 3 areas in question connected to one another and
involved a 12 x 9 x 2 cm area of bilateral subcutaneous tissue over the coccyx
and sacrum. Given the totality of circumstances and no rectal involvement, it
was decided at this time to perform wide excision down to healthy fatty tissue
of this area in hopes of definitively healing these fistula sites. This was
performed with cautery Bovie down to subcutaneous fat and all moist granulating
tissue involved with these fistulas was excised. A specimen was sent for just
culture and the another one was sent for pathology. Hemostasis was obtained
using cautery Bovie. Aquacel Ag was placed within the wound in the subcutaneous
tissues. Fluff and ABD pads were placed over the patient's excision site. 30
mLs of 0.25% plain Marcaine were injected in the subcutaneous tissues for
postoperative analgesia. Mesh undergarments were placed over the patient's
perineum to hold the bandage in place.
************************************************************************************************************
OPERATIVE REPORT (CO-SURGEON'S)
PREOPERATIVE DIAGNOSIS:
1. Perianal and lower gluteal cleft fistulizing actinomyces
POSTOPERATIVE DIAGNOSES:
1. Perianal and lower gluteal cleft fistulizing actinomyces
PROCEDURE:
1. Excision of pilonidal disease, final wound size 12 cm x 9 cm x 2 cm
ANESTHETIC: GETA and local anesthetic
Indications:
15-year-old y/o male who has been
dealing with perianal/gluteal cleft fitulizing disease for months. It has been
found to be due to actinomyces. This is failing to resolve completely with abx.
Dr. Saad his pediatric surgeon asked for me to be involved with Jveon's. Jveon
and his mother were seen by me in clinic preoperatively and surgery was
scheduled in conjunction with Dr. Saad.
Procedure:
Local anesthetic was placed into the planned dissection field. The fistula
probe was used to identify the extent of the multiple tracts. A pudendal nerve
block was performed and anoscopy was used to examine the anal canal. There was
no anal canal involvement with the fistulas. The fistulas in the lower gluteal
cleft tracted to the perianal skin bilaterally. There were multiple midline
pits of the gluteal cleft suspicious for pilonidal disease. The extent of
disease was marked out with a marker. Electrocautery was used to excise the
disease down to the level of the fascia overlying muscle/sacrum. Fascia was
left on the coccyx which appeared to be uninvolved by the infection. Hemostasis
was then achieved. The wound was packed with Aquacel dressing and gauze and
mesh underwear were placedd externally. The patient was transferred back to the
supine position. All sponge and needle counts were correct at the end of
procedure ×2. He was extubated and transferred to recovery. Intraoperative
findings and procedure was discussed with Jveon's mother with Dr. Saad. PMP
checked as Norco will be Rx by Dr. Saad upon discharge from the hospital this
weekend.
It's been suggested 11772 - Excision of pilonidal cyst or sinus; complicated
- The code does not allow for co-surgery which is another issue in it's own.
Something deep down tells me that there is a more appropriate code or additional code(s) for this:
OPERATIVE REPORT (PRIMARY SURGEON)
PREOPERATIVE DIAGNOSIS: Complex pilonidal cyst tracts with fistulae, chronic
actinomyces infection.
POSTOPERATIVE DIAGNOSIS: Complex pilonidal cyst tracts with fistulae, chronic
actinomyces infection.
PROCEDURE: Excision of complex pilonidal cyst disease with perianal fistulas,
excision size of 12 x 9 x 2 cm.
ANESTHESIA: General endotracheal anesthesia with 30 mLs of 0.25% plain Marcaine.
INTRAOPERATIVE FINDINGS:
1. Numerous fistulous draining tracts with granulation tissue underneath,
consistent with tracking pilonidal disease.
2. No perianal or rectal involvement of the process over the coccyx.
3. Muscle over the tip of the coccyx was viable and healthy.
4. On anoscopy, the anal mucosa appeared normal up to approximately 5 cm.
Digital rectal exam revealed normal tone.
15-year-old male who has had a nearly
8-month struggle with persistently draining perianal fistulae. These continued
to drain and were treated with numerous courses of antibiotics after initial
admission to the SIU Pediatric Hospitalist Service approximately 8 months ago.
He has had an extensive workup by the pediatric GI service and Crohn's disease
was ruled out. The patient had MRI studies, which revealed inflammation around
the tip of the coccyx and these complex fistulae involving the perianal skin,
but not involving the rectum. Due to the chronicity of the complex fistula
which grew actinomyces and has persistently grown this organism, a referral to
Dr. Paul Pacheco, Springfield Clinic Colorectal Specialist, was undertaken. He
was evaluated in Dr. Pacheco's clinic and scheduled today for a joint complex
excision of the involved tissues in hopes of healing totally by secondary
intention with the SIU Pediatric Surgery Service. The patient's mother provided
written surgical consent for excision of complex pilonidal cyst disease with
perianal fistulae under general anesthesia after she was made aware of the
possible complications of surgery, which may include but are not limited to:
Death, pain, bleeding, infection, possible hypertrophic scarring, possible
keloid formation, possible damage to the sphincters, possible damage to the
rectum and anus, possible need for wound VAC therapy, possible need for complex
flap closures, possible need for reexcisions in the future, possible need for
perioperative blood product administration and/or antibiotic therapy, possible
need for prolonged hospitalization, and consent was obtained.
DESCRIPTION OF PROCEDURE: Jveon was transported to the operating room. He was
positioned onto the operative table in the supine position after informed
consent was obtained. After adequate IV sedation and general endotracheal
anesthesia were administered, the patient was repositioned onto the operative
bed in the prone position. The patient's face, ET tube and extremities were all
padded and supported per HSHS OR protocol. Tape was used to spread the
patient's gluteal cheeks laterally. The patient's perianal skin was prepped and
draped in the usual sterile fashion using Betadine paint. A timeout procedure
was undertaken to correctly identify the patient, to verify his positioning onto
the operative table in the above-named position, and to verify the procedure to
be performed. All staff members present were in agreement on all accounts.
Attention was directed to the perianal skin, where 3 distinct draining fistula
sites with associated granulation tissue were noted. A digital rectal
examination was performed and revealed normal sphincter tone. Anoscopy was
performed with an anoscope, revealing normal rectal mucosa up to 5 cm with no
connecting fistulae. Probes were placed through the perianal skin fistula site
and these revealed that the 3 areas in question connected to one another and
involved a 12 x 9 x 2 cm area of bilateral subcutaneous tissue over the coccyx
and sacrum. Given the totality of circumstances and no rectal involvement, it
was decided at this time to perform wide excision down to healthy fatty tissue
of this area in hopes of definitively healing these fistula sites. This was
performed with cautery Bovie down to subcutaneous fat and all moist granulating
tissue involved with these fistulas was excised. A specimen was sent for just
culture and the another one was sent for pathology. Hemostasis was obtained
using cautery Bovie. Aquacel Ag was placed within the wound in the subcutaneous
tissues. Fluff and ABD pads were placed over the patient's excision site. 30
mLs of 0.25% plain Marcaine were injected in the subcutaneous tissues for
postoperative analgesia. Mesh undergarments were placed over the patient's
perineum to hold the bandage in place.
************************************************************************************************************
OPERATIVE REPORT (CO-SURGEON'S)
PREOPERATIVE DIAGNOSIS:
1. Perianal and lower gluteal cleft fistulizing actinomyces
POSTOPERATIVE DIAGNOSES:
1. Perianal and lower gluteal cleft fistulizing actinomyces
PROCEDURE:
1. Excision of pilonidal disease, final wound size 12 cm x 9 cm x 2 cm
ANESTHETIC: GETA and local anesthetic
Indications:
15-year-old y/o male who has been
dealing with perianal/gluteal cleft fitulizing disease for months. It has been
found to be due to actinomyces. This is failing to resolve completely with abx.
Dr. Saad his pediatric surgeon asked for me to be involved with Jveon's. Jveon
and his mother were seen by me in clinic preoperatively and surgery was
scheduled in conjunction with Dr. Saad.
Procedure:
Local anesthetic was placed into the planned dissection field. The fistula
probe was used to identify the extent of the multiple tracts. A pudendal nerve
block was performed and anoscopy was used to examine the anal canal. There was
no anal canal involvement with the fistulas. The fistulas in the lower gluteal
cleft tracted to the perianal skin bilaterally. There were multiple midline
pits of the gluteal cleft suspicious for pilonidal disease. The extent of
disease was marked out with a marker. Electrocautery was used to excise the
disease down to the level of the fascia overlying muscle/sacrum. Fascia was
left on the coccyx which appeared to be uninvolved by the infection. Hemostasis
was then achieved. The wound was packed with Aquacel dressing and gauze and
mesh underwear were placedd externally. The patient was transferred back to the
supine position. All sponge and needle counts were correct at the end of
procedure ×2. He was extubated and transferred to recovery. Intraoperative
findings and procedure was discussed with Jveon's mother with Dr. Saad. PMP
checked as Norco will be Rx by Dr. Saad upon discharge from the hospital this
weekend.