Please help! My surgeon wants me to code with 10060 but I disagree. Any suggestions?
With the patient in the supine position on the operating table, after he was properly identified, the operative site was marked and identified, preoperative antibiotics were administered within one hour of operation and pneumatic compression devices were placed on the lower extremities for thromboembolism prophylaxis, he was then intubated with the laryngeal mask and general anesthesia was induced without incident. The abdomen was prepped and draped sterilely. Exploration of the umbilicus revealed a tuft of chronic granulation tissue deep in the umbilicus. Probing this it did not go deeply and there was no tract extending into the abdomen itself. The skin just above this was incised and this was carried down through and into the sinus tract. At this point, it became apparent that the source of the chronic inflammation was a number of hairs that were present within this granulation tissue. This was all debrided. The area was cauterized and subsequently packed open with iodoform Nu Gauze. A sterile dressing was applied above this. The patient was extubated in the operating room and taken to the recovery room in good condition. There were no complications. Estimated blood loss was 3 mL. This is a contaminated case.
With the patient in the supine position on the operating table, after he was properly identified, the operative site was marked and identified, preoperative antibiotics were administered within one hour of operation and pneumatic compression devices were placed on the lower extremities for thromboembolism prophylaxis, he was then intubated with the laryngeal mask and general anesthesia was induced without incident. The abdomen was prepped and draped sterilely. Exploration of the umbilicus revealed a tuft of chronic granulation tissue deep in the umbilicus. Probing this it did not go deeply and there was no tract extending into the abdomen itself. The skin just above this was incised and this was carried down through and into the sinus tract. At this point, it became apparent that the source of the chronic inflammation was a number of hairs that were present within this granulation tissue. This was all debrided. The area was cauterized and subsequently packed open with iodoform Nu Gauze. A sterile dressing was applied above this. The patient was extubated in the operating room and taken to the recovery room in good condition. There were no complications. Estimated blood loss was 3 mL. This is a contaminated case.
