Help with CPT Code - anesthetic, the patient


Rome, GA
Best answers
I know it is late Friday afternoon, but this OP report came across my desk and I need some help coding it. Thanks in advance for any help.

Pre-Op Dx: Abdominal wall abscess
Post-OP Dx: Sinus tract to the subcutaneous tissues of the right upper abd wall.

Operation: Wound exploration with opening of the sinus tract and then packing with debridement.

Description: Following general anesthetic, the patient was draped and prepped in the usual sterile fashion. The previous opening in the abd wall now was probed and extended toward the patient's Right upper abdomen. A large cavity was reached which was then opened through which the patient had a moderate amount of purulent exudative material which has already been cultured. This entire tract now, or sinus, was opened from point A to point B, exposing what appeared to be some epithelialization of the floor which was then marsupialized and cauterized. Once this had been completed the area then could be packed with Iodoform packing for which I think routine dressing alone would most likely be adequate. Sterile dressings were applied. The patient was then taken to Recovery.