Lainie0559
Networker
The patient had surgery 11 months before by another physician.
The report reads:
The planned incision was marked. Essentially at the time of surgery she had two small less than 1 cm wounds with an intervening skin bridge and underlying tunnel. The skin was prepped with Betadine and sterile drapes were placed. Methylene blue was used to instill the tract so that I could identify a pseudobursa as we worked. The planned incisions were marked and 1% lidocaine with Epinephrine mixed 1:1 with 0.25% Marcaine plain was used to anesthetize the area. A 15 blade scalpel made the elliptical skin incision incorporating both small wounds and the intervening tunnel. The tissue was noted to be quite friable. I did essentially unroof the wound and at the base of the wound where the Methylene blue stained there was clearly residual AlloDerm. I debrided as much of the AlloDerm as I could and left what was already incorporated in place. I removed all traces of Methylene blue thus verifying that I removed all of the colonized tissue. 1000 cc of normal saline was used to pulse irrigate the wound. The wound was reapproxiated using 3-0 Nylon interrupted sutures. Total wound closure length is 9 cm. This was toleratd well. Acticoate and a dry dressing were placed.
How could you code this?
Any suggestions are greatly appreciated. Thanks in advance.
The report reads:
The planned incision was marked. Essentially at the time of surgery she had two small less than 1 cm wounds with an intervening skin bridge and underlying tunnel. The skin was prepped with Betadine and sterile drapes were placed. Methylene blue was used to instill the tract so that I could identify a pseudobursa as we worked. The planned incisions were marked and 1% lidocaine with Epinephrine mixed 1:1 with 0.25% Marcaine plain was used to anesthetize the area. A 15 blade scalpel made the elliptical skin incision incorporating both small wounds and the intervening tunnel. The tissue was noted to be quite friable. I did essentially unroof the wound and at the base of the wound where the Methylene blue stained there was clearly residual AlloDerm. I debrided as much of the AlloDerm as I could and left what was already incorporated in place. I removed all traces of Methylene blue thus verifying that I removed all of the colonized tissue. 1000 cc of normal saline was used to pulse irrigate the wound. The wound was reapproxiated using 3-0 Nylon interrupted sutures. Total wound closure length is 9 cm. This was toleratd well. Acticoate and a dry dressing were placed.
How could you code this?
Any suggestions are greatly appreciated. Thanks in advance.