Help with CPT for Abscess


Pennsauken, NJ
Best answers

I need assistance with a procedure note. I'm new to surgery and I'm stuck. I don't know if I'm missing something. I'm looking at 49020 for the below procedure but that seems way off. I was thinking off a regular abscess code 10060. I also coded 49084 for wash and 97606 for VAC. Any thoughts would help. Thank You

DESCRIPTION OF PROCEDURE: The patient was placed in the supine position and timeout was performed with the correct patient and correct procedure identified. The patient was then sedated. The patient did not receive any preoperative antibiotics. The VAC was taken down and the patient's wound is in the left lower quadrant with some undermining and tunneling laterally, superiorly towards the right as well as laterally towards the left. The wound does appear to be granulating around the Malecot drain that was placed in the colocutaneous fistula. The Malecot was removed and the patient does have a right upper quadrant IR abscess drain that was injected with normal saline. We observed that the drain does appear to communicate with the subcutaneous space tunneling down towards the right lower quadrant. We then washed and irrigated the wound in the undermined areas. We then replaced the Malecot 32-French into the colocutaneous fistula. We then placed a white sponge cut in pieces underneath the undermining and to cover the bowel. We then placed 2 NG tubes, 1 towards the right undermining and 1 towards the left undermining. We then covered the NG tube using a black sponge. Then using the tape in the KCI VAC set, we secured the NG tubes, the Malecot, and the black sponge to the skin. We then connected the tract pad to the VAC and we did have a good seal. The plan for her is to return on Friday for another look. The NG tubes will be hooked up to wall suction when she reaches the floor. The counts were correct at the end of the case. The main wound skin edge was about 15 x 5 cm. There was an additional significant amount of undermining medial and lateral to this.