Lynne77
Contributor
Hello-
New to coding breast reconstruction. Per the op note, operations performed: 1) Exploration and washout of right breast, 2) Removal of right breast implant. How do I code the "Exploration and washout"? The op note states, "After a robust timeout had been completed, I made an inframammary fold incision around her spitting suture site. I then dissected down to the subcutaneous tissue until I identified the implant that was intact. I removed the implant and removed approximately 5 ml of murky slimy fluid that did not appear to be over purulence, but did appear to be concerning. I then copiously irrigated with 3 liters of antibiotic irrigation with pulse lavage and did not feel comfortable with an exchange of an implant given the intraoperative findings (then goes on to document the placement of a drain and suturing).
Any help would be greatly appreciated! Thank you!
New to coding breast reconstruction. Per the op note, operations performed: 1) Exploration and washout of right breast, 2) Removal of right breast implant. How do I code the "Exploration and washout"? The op note states, "After a robust timeout had been completed, I made an inframammary fold incision around her spitting suture site. I then dissected down to the subcutaneous tissue until I identified the implant that was intact. I removed the implant and removed approximately 5 ml of murky slimy fluid that did not appear to be over purulence, but did appear to be concerning. I then copiously irrigated with 3 liters of antibiotic irrigation with pulse lavage and did not feel comfortable with an exchange of an implant given the intraoperative findings (then goes on to document the placement of a drain and suturing).
Any help would be greatly appreciated! Thank you!