NPSDEB
Networker
I need help with a CPT code. I will attach the OP report. He wanted to bill 20102 and I know that is incorrect but I couldn't find anything else to bill. Any pointers?
PROCEDURE:
Exploration and debridement of nonhealing abdominal wound.
Excision of abdominal stitch abscess.
ANESTHESIA: General.
BRIEF HISTORY: who has had several previous surgeries to his abdomen. These include a previous choledochoduodenostomy and Roux-en-Y pancreaticojejunostomy in . He then underwent transection of his distal stomach and formation of a loop gastrojejunostomy. He has an open draining wound present to the central aspect of his abdomen. Studies have shown no evidence of pancreatic drainage from this wound. I have offered surgical exploration of this persistent draining sinus tract in order to identify the cause of the persistent nonhealing wound. I stressed that I could make no "guarantee" that this surgery would resolve his ongoing wound difficulty. The risks of infection, wound healing difficulties, and need for additional surgical intervention were explained. He is scheduled for this surgery today.
DESCRIPTION OF PROCEDURE: was seen in the preoperative examination area. Verification that he continued to have a small sinus tract with drainage was performed. He was then brought into the operative suite and placed supine. General anesthesia was administered. His abdomen was widely prepped. Sterile towels and drapes were placed in a standard fashion.
Probing of the sinus tract showed that this extended slightly inferiorly towards the abdominal fascia. The skin and subcutaneous tissue overlying the sinus tract was incised with a knife and electrocautery. Dissection followed the sinus tract onto the fascial closure. At the base of the sinus tract was found to be a Prolene suture. This was a running suture that was present at the base and there was no single suture that was present. However, clearly, the tissue surrounding the suture had a friable consistency similar to that seen from a stitch abscess.
The exposed portion of the Prolene suture was retracted and then transected at its right and left portion. There was no purulent fluid present. Probing showed no further extension past where the Prolene stitch was present. The base of the wound was debrided with a curette. Wound was irrigated with normal saline. Saline-soaked gauze packing and overlying sterile dressing was applied. He was then awoken from the anesthetic without difficulty. He was transferred to a stretcher and brought to the postanesthesia recovery area in stable condition.
Thank you in advance for any and all help.
PROCEDURE:
Exploration and debridement of nonhealing abdominal wound.
Excision of abdominal stitch abscess.
ANESTHESIA: General.
BRIEF HISTORY: who has had several previous surgeries to his abdomen. These include a previous choledochoduodenostomy and Roux-en-Y pancreaticojejunostomy in . He then underwent transection of his distal stomach and formation of a loop gastrojejunostomy. He has an open draining wound present to the central aspect of his abdomen. Studies have shown no evidence of pancreatic drainage from this wound. I have offered surgical exploration of this persistent draining sinus tract in order to identify the cause of the persistent nonhealing wound. I stressed that I could make no "guarantee" that this surgery would resolve his ongoing wound difficulty. The risks of infection, wound healing difficulties, and need for additional surgical intervention were explained. He is scheduled for this surgery today.
DESCRIPTION OF PROCEDURE: was seen in the preoperative examination area. Verification that he continued to have a small sinus tract with drainage was performed. He was then brought into the operative suite and placed supine. General anesthesia was administered. His abdomen was widely prepped. Sterile towels and drapes were placed in a standard fashion.
Probing of the sinus tract showed that this extended slightly inferiorly towards the abdominal fascia. The skin and subcutaneous tissue overlying the sinus tract was incised with a knife and electrocautery. Dissection followed the sinus tract onto the fascial closure. At the base of the sinus tract was found to be a Prolene suture. This was a running suture that was present at the base and there was no single suture that was present. However, clearly, the tissue surrounding the suture had a friable consistency similar to that seen from a stitch abscess.
The exposed portion of the Prolene suture was retracted and then transected at its right and left portion. There was no purulent fluid present. Probing showed no further extension past where the Prolene stitch was present. The base of the wound was debrided with a curette. Wound was irrigated with normal saline. Saline-soaked gauze packing and overlying sterile dressing was applied. He was then awoken from the anesthetic without difficulty. He was transferred to a stretcher and brought to the postanesthesia recovery area in stable condition.
Thank you in advance for any and all help.