Incision and debridement - scrotal Fournier's gangrene CPT help

Willow11

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PROCEDURE: The patient was brought to the operating room placed on the operating table. After administration of general anesthesia was placed in lithotomy position. The scrotum and perineum were thoroughly inspected. There was erythema of the scrotum spreading onto the lower aspect of the inguinal canals bilaterally. There was purulence drainage from the perirectal area. The skin of the perineum was abnormal. There was a approximately 3 cm x 3 cm in diameter eschar on the inferior aspect of the scrotum. I had made an incision circumferentially around the eschar to excise this area and then had entered a plane that took me to the perianal areas bilaterally. At this point I was able to continue the dissection superiorly. Identified normal scrotal tissue. It did not appeared that the scrotal contents themselves were involved. There was a plane of dissection bilaterally that proceeded to normal tissue in the inguinal canal. I did make a counter incision in both inguinal regions and each of these was eventually packed. All necrotic tissue on the perineum was removed. Bleeding was controlled electrocautery. At the conclusion of the incision and debridement I placed a Kerlix dressing beginning inferiorly protruding from the perirectal incision. I then made sure that the Kerlix was not in contact with every surface including up into the inguinal canals. I had to pack the left incision externally. The dressing material seen coming out of the right inguinal canal is proceeding from inside to outside it does not represent a separate piece of packing material. I used a 2 nylon to bring the edges of the perineal defect into better coaptation to trap the dressing in place. I then used a stapler to similarly bring the edges of the scrotum together. These are temporary and only used to maintain the dressing in position. I did place a Foley catheter in the procedure in did retrieve clear yellow urine. I did not encounter the urethra at any time during the dissection.

It looks like to me that Provider did a scrotal exploration - 55110 and I am not sure on the necrotic tissue removal and if the packing of wound is included

Any help is appreciated
 

OpenClaims

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Miami, FL
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Was the necrotic tissue on the external or internal scrotum? Also, I believe the packing would be included with the 55110.
 
Messages
336
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This sounds like Fournier's gangrene with excision of the gangrene areas which did involve the scrotum and perineum with normal intra-scrotal contents. I would suggest 11004
 
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