I would greatly appreciate any advice/suggestions with coding the op report below. I am not sure how to code this, but am leaning towards an unlisted code. Thank you in advance for your help!
Post-op Dx: Sinus tract with foreign body, Prolene suture, with a stitch reaction abscess cavity in the perianal region
Op px performed:
1. Removal of foreign body (Prolene suture)
2. Curettage of the sinus tract and abscess cavity wall
3. Open wound drainage and iodoform packing
Findings: There was a persistent and recurrent sinus tractand stitch reaction abscess cavity with a Prolene suture foreign body along the perianal region.
Description of Px: The patiet was placed in the supine position, was given general anesthesia and then placed in the prone position. The bed was then positioned in a jack-knife position and both gluteal areas were then spread open with the use of surgical tapes. The perianal region was then painted with Betadine solution followed by application of routine sterile drapes. A blunt-tipped malleable metal probe was inserted through the sinus tract, which probes deep down to approximately about 3 cm in depth which extends down into the perirectal region. I put my left index finger inside the anal cavity, which showed no evidence of any induration in the mucosa in the anal wall. The metal probe seems to stop the perianal region with no evidence of any extension into the lumen of the anal cavity. This was repeated several times, which again proves no communixation at all into the anal cavity. I then proceeded to perform a curettage of the sinus tract using a metal sharp curette and then the sinus tract and abscess cavity was then irrigated copiously with double antibiotic solution and Betadine solution. Iodoform packing was inserted into the sinus tract cavity and then followed by application of dry dressing. The patient tolerated the procedure well and left the operating room in stable condition.
Post-op Dx: Sinus tract with foreign body, Prolene suture, with a stitch reaction abscess cavity in the perianal region
Op px performed:
1. Removal of foreign body (Prolene suture)
2. Curettage of the sinus tract and abscess cavity wall
3. Open wound drainage and iodoform packing
Findings: There was a persistent and recurrent sinus tractand stitch reaction abscess cavity with a Prolene suture foreign body along the perianal region.
Description of Px: The patiet was placed in the supine position, was given general anesthesia and then placed in the prone position. The bed was then positioned in a jack-knife position and both gluteal areas were then spread open with the use of surgical tapes. The perianal region was then painted with Betadine solution followed by application of routine sterile drapes. A blunt-tipped malleable metal probe was inserted through the sinus tract, which probes deep down to approximately about 3 cm in depth which extends down into the perirectal region. I put my left index finger inside the anal cavity, which showed no evidence of any induration in the mucosa in the anal wall. The metal probe seems to stop the perianal region with no evidence of any extension into the lumen of the anal cavity. This was repeated several times, which again proves no communixation at all into the anal cavity. I then proceeded to perform a curettage of the sinus tract using a metal sharp curette and then the sinus tract and abscess cavity was then irrigated copiously with double antibiotic solution and Betadine solution. Iodoform packing was inserted into the sinus tract cavity and then followed by application of dry dressing. The patient tolerated the procedure well and left the operating room in stable condition.