Help with Op Report

kibbit99

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Hi, I have this operative report, but I am not sure which I & D code best supports this case. I am looking at 27030, but I can't validate with dx. Please help. Two incisions is throwing me off as well. Thank you so much!

Dx: Psoas abscess, RT side
Infected RT Hip

PROCEDURE: pt admitted to hospital almost 2 wks prior to her trip to the operating room. She had medical issues. She was known to have chronic leukemia and she was found to have what appeared to be an abscess in her RT buttock and also a psoas abscess on the right side. These were dx by CAT scan. Interventions radiology was involved and drained 30ml of pus from the abscess area in the right hip. + for streptococcus. It was felt that she needed to have both these areas surgically drained. I was contemplating and explant procedure for her right hip, which had been replaced in 2002.

I thought we should at least drain the hip locally first and go back and do the explant if necessary later. She had been scheduled for several days and for one reason or another was not able to get down to the operating room.

Pt was placed under general anesthesia and since we were planning on exploring the psoas area in the right hip and right hip itself was rolled up onto a bean bag to about a 45 degree ankle so we had access to her hip and iliac crest. Following the application of sterile drapes and standard ortho prep using ChloraPrep we did a final time out and then first made an incision over the iliac crest. This was longitudinally line with the crest. It was taken down to the bone of the iliac crest. The soft tissues were reflected off gently and the interior side of the pelvis was exposed. We were posteriorly, way far medically posteriorly and got no definite return of purulent material. It was noted that her soft tissues did seem to be rather boggy and almost water logged. After that we had been through the psoas tendon and muscle we decided to was the wound out with sterile wash out and then close it. We closed the fascia over the iliac crest with interrupted 0 Vicryl figure-of-eight sutures.


Wound was also closed. We then mad an incision through the previous hip scar. This was able to find the tendons of the hip. We explored anteriorly and posteriorly down to bone and got no definite evidence of purulence. I felt that it could have been an hold hematoma although it certainly did not have the appearance of old blood. We spent a good deal of time exploring inferiorly and superiorly, medially and I explored over the front of the hip joint and I explored into the back of the hip joint, likewise of the top of the proximal femur. Way up in the buttock I explored into the deep fibers of the gluteus maximus muscle and still got no collection of pus. We washed out thoroughly with sterile saline and then since we found no evidence of purulent drainage we closed the deep fascia with several interrupted Prolene sutures in deep fascia and interrupted mattress sutures in skin. We did leave a Penrose drain in this wound just in case patient did have any deep infection that we had missed and wanted to drain out. Cultures were sent to lab from both wounds for aerobic and anaerobic cultures. After routine skin closures sterile dressings were placed over both hips and she was awakened.
 

kibbit99

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I looked at 26990, but the physician did not drain anything. It looked more like an arthrotomy. I gave the physician the list of I & D/arthrotomy codes to see what he thinks.

Thanks for helping.
 

mbort

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I'm with Treetoad on this one, 26990, the intent was for drainage. Arthrotomies usually go into joints and I dont see that in this note.

Mary, CPC, COSC
 
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