Would you please help with CPT and modifiers needed. Thinking 10061 but not sure how to show multiple abscess in multiple sites..... Thank you !!
Bilateral buttocks, bilateral thighs and bilateral shoulders were then prepped and draped in standard fashion. The procedure began on his left side where he already had 2 incisions from previous incision and drainage performed October 6th. Examination of this wound noted that there were deep pockets, deep to these 2 incisions that had yet to be drained. These pockets were opened and allowed to communicate with the incision. There was a tract between the 2 wounds that communicated and a Penrose drain was placed through these. A further distal fluctuant area had been preoperatively noted and an incision was made in this portion and the pus evacuated and sent off for specimen. This area also communicated with the previously drained wounds and a second Penrose was placed. These wounds were then irrigated with pulse lavage and then packed with Xeroform gauze. The left buttock was addressed in a similar fashion; where there had been preoperative ultrasound 2 large abscesses and soft tissue. The entire skin was indurated and the incision was made over the most fluctuant area which returned the pus. Of note, these abscesses in this space appeared to be quite complex with evidence of significant chronicity as there was not one large simple cavity, but rather a serpentine multilevel infiltrating pockets and sinuses to these cavities. They were connected as best they could and multiple incisions were made and these were lengthened using a Penrose as packing with so much gauze and appeared to be significantly painful and a significant burden in terms of wound care. The cavities were irrigated with the pulse lavage and then packed with Xeroform in a similar manner. The right buttock and thigh were also dressed in a similar manner. Of note, there was evidence of drainage already established with some sinus tracts that ran from the multiple abscess cavities to the skin and these were utilized as the point of entry and the loculations were broken up and the wounds irrigated, linked with a Penrose and packed with Xeroform gauze. There were also 2 right lateral thigh abscesses that had been identified and these did not connect with the other cavities and were each incised, drained, irrigated and packed in the described fashion. Attention then turned towards the bilateral shoulders. In the right there was a draining sinus that once opened, returned a significant amount of pus and a counter incision was then made and this wound was again irrigated, packed and drained with a Penrose. Examination of the left shoulder noted no evidence of fluid collection either by palpation or ultrasound; attempted aspiration with an 18 gauge needle. No incisions were made on the shoulder. These multiple incisions were then covered with a 4x4, as well as ABD pads and tape.
Bilateral buttocks, bilateral thighs and bilateral shoulders were then prepped and draped in standard fashion. The procedure began on his left side where he already had 2 incisions from previous incision and drainage performed October 6th. Examination of this wound noted that there were deep pockets, deep to these 2 incisions that had yet to be drained. These pockets were opened and allowed to communicate with the incision. There was a tract between the 2 wounds that communicated and a Penrose drain was placed through these. A further distal fluctuant area had been preoperatively noted and an incision was made in this portion and the pus evacuated and sent off for specimen. This area also communicated with the previously drained wounds and a second Penrose was placed. These wounds were then irrigated with pulse lavage and then packed with Xeroform gauze. The left buttock was addressed in a similar fashion; where there had been preoperative ultrasound 2 large abscesses and soft tissue. The entire skin was indurated and the incision was made over the most fluctuant area which returned the pus. Of note, these abscesses in this space appeared to be quite complex with evidence of significant chronicity as there was not one large simple cavity, but rather a serpentine multilevel infiltrating pockets and sinuses to these cavities. They were connected as best they could and multiple incisions were made and these were lengthened using a Penrose as packing with so much gauze and appeared to be significantly painful and a significant burden in terms of wound care. The cavities were irrigated with the pulse lavage and then packed with Xeroform in a similar manner. The right buttock and thigh were also dressed in a similar manner. Of note, there was evidence of drainage already established with some sinus tracts that ran from the multiple abscess cavities to the skin and these were utilized as the point of entry and the loculations were broken up and the wounds irrigated, linked with a Penrose and packed with Xeroform gauze. There were also 2 right lateral thigh abscesses that had been identified and these did not connect with the other cavities and were each incised, drained, irrigated and packed in the described fashion. Attention then turned towards the bilateral shoulders. In the right there was a draining sinus that once opened, returned a significant amount of pus and a counter incision was then made and this wound was again irrigated, packed and drained with a Penrose. Examination of the left shoulder noted no evidence of fluid collection either by palpation or ultrasound; attempted aspiration with an 18 gauge needle. No incisions were made on the shoulder. These multiple incisions were then covered with a 4x4, as well as ABD pads and tape.