rkindlund
Guest
Not sure what code to assign for the procedure our doc is planning. He is out of the office so I can't ask him if a "cystic cavity" is itself a cyst, a mass, a lesion or just another I&D basically. Here are the pertinent parts of his H&P.
80 year-old gentleman who I met at the beginning of May.* He was referred with an infected sebaceous cyst over his left upper back.* He was started on antibiotics and taken to the operative suite for I & D.* A large amount of purulent material and sebaceous material were removed.* The wound was cleared.* There was granulation tissue noted at the bed and it was loosely closed with nylon suture.* He has defervesced.* He has had minimal discomfort, minimal drainage.* There continues to be residual cyst cavity and a small amount of drainage with palpation of the area today.*
BACK:* There is an area approximately 3 x 4 cm in area of scarring, and a small amount of drainage from the previous I & D site is noted with palpation.* There is no diffuse cellulitis and no tenderness.* This is slightly to the left of midline at the mid-back.
IMPRESSION:* Residual cystic cavity from I & D of an infected sebaceous cyst, dramatically improved after I & D and debridement.
PLAN:* We will plan full excision under local anesthetic.
80 year-old gentleman who I met at the beginning of May.* He was referred with an infected sebaceous cyst over his left upper back.* He was started on antibiotics and taken to the operative suite for I & D.* A large amount of purulent material and sebaceous material were removed.* The wound was cleared.* There was granulation tissue noted at the bed and it was loosely closed with nylon suture.* He has defervesced.* He has had minimal discomfort, minimal drainage.* There continues to be residual cyst cavity and a small amount of drainage with palpation of the area today.*
BACK:* There is an area approximately 3 x 4 cm in area of scarring, and a small amount of drainage from the previous I & D site is noted with palpation.* There is no diffuse cellulitis and no tenderness.* This is slightly to the left of midline at the mid-back.
IMPRESSION:* Residual cystic cavity from I & D of an infected sebaceous cyst, dramatically improved after I & D and debridement.
PLAN:* We will plan full excision under local anesthetic.