Here I have a case that is as follows:
INDICATIONS: Persistent bleeding.
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*
HISTORY: Patient had pacemaker extraction. Initially we placed a wound VAC sponge. Possibly because it was oversized it was difficult to remove and then removing some of the muscle but it started to bleed and continuously ooze. We go in for exploration
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FINDINGS
The muscle bed especially in regions in which I had debrided necrotic looking pseudocapsule was oozing. I tried electrocautery without effect. I used Surgicel on the bleeding points with direct pressure x15 minutes.
I then placed sutures out on the muscle bed and then used suture to oversew the region for tamponade purposes.
*
The wound was then packed with iodoform.
The labs came back negative for bacterial growth. I want to say it is 20101 for the wound exploration...but can you bill for a wound that was created by the provider? I'm also leaning heavily towards 10180 but due to the labs coming back negative I don't think that's it either.
Help!
INDICATIONS: Persistent bleeding.
*
*
HISTORY: Patient had pacemaker extraction. Initially we placed a wound VAC sponge. Possibly because it was oversized it was difficult to remove and then removing some of the muscle but it started to bleed and continuously ooze. We go in for exploration
*
FINDINGS
The muscle bed especially in regions in which I had debrided necrotic looking pseudocapsule was oozing. I tried electrocautery without effect. I used Surgicel on the bleeding points with direct pressure x15 minutes.
I then placed sutures out on the muscle bed and then used suture to oversew the region for tamponade purposes.
*
The wound was then packed with iodoform.
The labs came back negative for bacterial growth. I want to say it is 20101 for the wound exploration...but can you bill for a wound that was created by the provider? I'm also leaning heavily towards 10180 but due to the labs coming back negative I don't think that's it either.
Help!