bda23054
Networker
Could use some much appreciated help coding the below:
PREOPERATIVE DIAGNOSIS
Multiloculated abscess to the right back- scapula area.
POSTOPERATIVE DIAGNOSIS
Multiloculated abscess to the right back- scapula area.
NAME OF OPERATION
Right back complex multiloculated abscess incision and drainage with surgical debridement and wound V.A.C. dressing placement.
FINDINGS
CT scan showed multiloculated abscess over the right scapula area. This was consistent with purulent drainage from multiple pockets along edematous fluctuant area to the right scapula area. With an oblique incision over this area, the subcutaneous tissue appeared to be essentially necrotic and had purulent drainage scattered through several pockets down to the muscle. The muscle fascia was thickened. The underlying muscle appeared viable. More medially there was tracking down actually under the belly of the muscle and some communication in that area, but no other deeper tracts were appreciated besides this medial one that had a minimal amount of purulent drainage to it. Again, there were multiple areas of purulent drainage with any pressure to the overlying skin in the subcutaneous tissue. No one large cavity with a lot of purulent material was appreciated. The wound once the debridement was complete, started with indurated area, the post procedure opened area was 10.5 x 4 x 2.5 cm with exposed muscle at the base, some nonviable fascial tissue was removed at the base. The medial side undermined about 3 cm inferior side about 2-3 cm laterally 1.5 and superiorly maybe 1 cm. Hemostasis was visualized. Wound V.A.C. was in place.
DESCRIPTION OF OPERATION
The procedure as well as indications, benefits and potential risks were explained to the patient. All questions were answered. With consent obtained, the patient was taken to the Operative Suite, placed in the supine position on the cart and general anesthesia was initiated and airway protected. The patient was then rolled to a prone position on the operative table. The right shoulder was exposed, prepped and draped in the usual sterile fashion. The above findings were noted. The most fluctuant area more lateral to the edematous erythematous swollen area was incised with electrocautery in an oblique fashion directed over the swollen area cephalad. The purulent drainage was encountered. This was cultured at this point. The overlying skin draining purulent drainage and underlying fat was removed from this opening. It was digitally explored and multi-loculations were found as per CT scan. Again, no overwhelming enlarged cavity or tract was able to be found initially and more of the fibrotic nonviable subcutaneous tissue with abscess loculations were removed. The cavity was widened to the above dimensions with electrocautery and again under all the edges the subcutaneous tissue that had purulent drainage abscess within it was removed grossly. The overlying skin did appear to be somewhat viable still around the edges, though edematous. I did not aggressively debride the skin any further than the actual opening and with the plan of a second look in 48-hours. Medially, it was noted the patient did have a tract somewhat into the muscle. This was explored digitally and any loculations were broke up. Irrigation with 2 liters of Betadine tinged saline followed by a liter of sterile saline was then used, with electrocautery used for hemostasis of inflammatory bloody oozing points throughout the cavity. Silver sponge one thin piece was placed medially and in the undermined area with larger piece of sponge over the top of this cut to fit the opening and into the undermined areas. Again, there were 2 pieces of sponge in the cavity. Occlusive dressing was placed over this site and the negative pressure foot pad was placed to the middle of this incision with some foam placed around the tubing to minimize pressure into the skin. The patient was then cleansed of Betadine prep and rolled back onto the cart with all sponge and instrument counts correct. The patient was awakened and taken to the Recovery Room in stable and satisfactory condition.
PREOPERATIVE DIAGNOSIS
Multiloculated abscess to the right back- scapula area.
POSTOPERATIVE DIAGNOSIS
Multiloculated abscess to the right back- scapula area.
NAME OF OPERATION
Right back complex multiloculated abscess incision and drainage with surgical debridement and wound V.A.C. dressing placement.
FINDINGS
CT scan showed multiloculated abscess over the right scapula area. This was consistent with purulent drainage from multiple pockets along edematous fluctuant area to the right scapula area. With an oblique incision over this area, the subcutaneous tissue appeared to be essentially necrotic and had purulent drainage scattered through several pockets down to the muscle. The muscle fascia was thickened. The underlying muscle appeared viable. More medially there was tracking down actually under the belly of the muscle and some communication in that area, but no other deeper tracts were appreciated besides this medial one that had a minimal amount of purulent drainage to it. Again, there were multiple areas of purulent drainage with any pressure to the overlying skin in the subcutaneous tissue. No one large cavity with a lot of purulent material was appreciated. The wound once the debridement was complete, started with indurated area, the post procedure opened area was 10.5 x 4 x 2.5 cm with exposed muscle at the base, some nonviable fascial tissue was removed at the base. The medial side undermined about 3 cm inferior side about 2-3 cm laterally 1.5 and superiorly maybe 1 cm. Hemostasis was visualized. Wound V.A.C. was in place.
DESCRIPTION OF OPERATION
The procedure as well as indications, benefits and potential risks were explained to the patient. All questions were answered. With consent obtained, the patient was taken to the Operative Suite, placed in the supine position on the cart and general anesthesia was initiated and airway protected. The patient was then rolled to a prone position on the operative table. The right shoulder was exposed, prepped and draped in the usual sterile fashion. The above findings were noted. The most fluctuant area more lateral to the edematous erythematous swollen area was incised with electrocautery in an oblique fashion directed over the swollen area cephalad. The purulent drainage was encountered. This was cultured at this point. The overlying skin draining purulent drainage and underlying fat was removed from this opening. It was digitally explored and multi-loculations were found as per CT scan. Again, no overwhelming enlarged cavity or tract was able to be found initially and more of the fibrotic nonviable subcutaneous tissue with abscess loculations were removed. The cavity was widened to the above dimensions with electrocautery and again under all the edges the subcutaneous tissue that had purulent drainage abscess within it was removed grossly. The overlying skin did appear to be somewhat viable still around the edges, though edematous. I did not aggressively debride the skin any further than the actual opening and with the plan of a second look in 48-hours. Medially, it was noted the patient did have a tract somewhat into the muscle. This was explored digitally and any loculations were broke up. Irrigation with 2 liters of Betadine tinged saline followed by a liter of sterile saline was then used, with electrocautery used for hemostasis of inflammatory bloody oozing points throughout the cavity. Silver sponge one thin piece was placed medially and in the undermined area with larger piece of sponge over the top of this cut to fit the opening and into the undermined areas. Again, there were 2 pieces of sponge in the cavity. Occlusive dressing was placed over this site and the negative pressure foot pad was placed to the middle of this incision with some foam placed around the tubing to minimize pressure into the skin. The patient was then cleansed of Betadine prep and rolled back onto the cart with all sponge and instrument counts correct. The patient was awakened and taken to the Recovery Room in stable and satisfactory condition.
, there was no abscess present. He closed and then changed the bandage. This was an ongoing problem for the patient. Would code 23030 still be a valid code?