op note added
Would something from the range 11040 - 11042 be appropriate? Without the operative notes I'd hesitate to direct you there, but if these are among the codes you were considering I'd say they were strong contenders. If all else fails, see if the Dr can help you narrow down the alternates you've come up with.
I would have to say the 11040-11042 aren't really there either. There are several codes that almost work, but aren't quite what I need. See note below:
PREOPERATIVE DIAGNOSES:
1. Chronic perineal wound.
2. Crohn's disease.
3. Fever.
POSTOPERATIVE DIAGNOSES:
1. Chronic perineal wound.
2. Crohn's disease.
3. Fever.
PROCEDURES:
1. Exploration and washout of chronic perineal wound.
ESTIMATED BLOOD LOSS: 100 cc.
COMPLICATIONS: None.
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS: The patient is a 29-year-old gentleman with a history of total proctocolectomy for Crohn's disease. He has a permanent ileostomy. The patient was admitted with pain, drainage and leukocytosis. The patient has re-opened up a chronic perineal wound. CT scan and pelvic MRI both show no evidence of pelvic abscess. However, the patient is having continuous drainage and some bloody discharge and pain in his perineum. Exploration at the bedside is difficult to examine due to pain. There appear to be two wounds potentially communicating. The patient was managed conservatively for several days; however, he persisted with fever and pain and is now brought to the operating room for exploration of his wounds.
DESCRIPTION OF PROCEDURE: The patient is placed on the table in supine position. General endotracheal anesthesia was established. The patient was then placed up into full lithotomy position in candy cane stirrups. Perineum was prepped and draped in aseptic fashion. In the position where the patient's anus used to be there is a 1 cm hole with hypertrophic granulation tissue coming up out of the wound. Exploration with a Q-Tip revealed this to be about 4 cm deep. There was heavy bleeding from the granulation tissue. In the patient's gluteal cleft, about 3 cm away toward the coccyx, there was a perineal wound. Exploration with a Q-Tip revealed that these two wounds communicated deep down. After injecting with 0.5% Marcaine with epinephrine, we made a vertical incision along the gluteal cleft connecting the two wounds. We cut down about 2-3 cm through old scar tissue and found a deep bed of chronic granulation tissue with heavy vascularity and bleeding. The granulation tissue was cauterized and eliminated. We had to use significant cautery to control the bleeding. Ultimately, the wound was packed with Surgicel and pressure was held for about 5-10 minutes. The wound was again explored and further cauterization was undertaken. Again, we packed the wound with a new Surgicel and held pressure. Finally the bleeding stopped. There was no abscess or further sinus tracts up into the pelvis. The wound was about 6 cm long and 4 cm deep. The wound was packed and left open. Mesh underwear and fluff gauze was applied. The patient was awakened, extubated and brought to the recovery room in good condition. In a couple days' time we will remove the packing and apply wound VAC.
