Experts please help w/this op for I&D ?

Justarose

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I could really use some help - thank you

POSTOPERATIVE DIAGNOSES:
1. L5-S1 disk extrusion, left.
2. Possible superficial bursa infection versus abscess.

PROCEDURES PERFORMED:
1) Irrigation and debridement superficial to
lumbar fascia above L5-S1 level.
2) Cultures taken

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Minimal.

INDICATIONS FOR THE PROCEDURE: XXX presented for an elective L5-S1 diskectomy. He has failed conservative treatment. The risks and benefits have been explained; they include but are not limited to infection, dural spinal fluid leak, failure to relief pain, etc.

TECHNIQUE: The patient presented to the holding area. The risks and benefits were again explained to him. A signed written consent was obtained. He was then taken to the operative suite. A time out was called and confirmed. Sign your site had been done and documented. DVT prophylaxis and preoperative antibiotics were in place. The patient was prepped and draped in a sterile fashion in prone position on Skytron table. I inserted the Steinmann pin in order to place symmetric dilators and tubes, dilators etc. Once I got to the second round of dilation tools, I noticed return of small amounts of what almost looked purulent material. This could have been the necrotic fat. At that time, I took out the dilator tubes and took cultures. I thoroughly irrigated and probed the wound. There was nothing that seem to track deep to the muscle or fascial layer. It felt all superficial. I broke up any loculations. I did get another 10 to 15 cc of this purulent looking material. Again, more cultures were taken. I copiously irrigated the wound with 200 cc of normal saline. I then reapproximated the wound with interrupted nylon sutures.

The plan is to evaluate the cultures and check on repeat MRI to make sure nothing tracks deep to the fascia or down to the neurologic elements. If cultures are negative and there is no deep infection, we will proceed with the discectomy hopefully within the next two weeks.

Just don't even want to tell you what I think because I think I am so off : please help
Thanks !
 

RebeccaWoodward*

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My first thought was 22015. But, since your surgeon indicated..."There was nothing that seem to track deep to the muscle or fascial layer. It felt all superficial", 22015 doesn't seem to fit. Subfascial=below fascia. So...then it seems you're left with 10140 or 10060/61. I'm learning towards 10061 versus 10140. IMHO, I would query the physician so that he can decide which code meets the complexity of his procedure.
 

rajalakshmir

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i think the cpt code 11042 suits , since they say debridement .any suggestions
 
Last edited:

RebeccaWoodward*

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I did see debridement in the heading of the op note but I only saw "copiously irrigated" in the body of the op note. I don't always equate debridement with copiously irrigated. I tend to look for certains terms if the word "debridement" is not within the body of the note...(i.e. forceful irrigation, pulse lavage...) But again, that's only me...
 
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