Incision & drainage w/ debridement of ankle abscess


Perryville, MO
Best answers
I'm leaning towards 10061 for this operative note, since he incised and drained and did not specify deep into subc or muscle as in 27603. Physician also did some debridement of necrotic/fatty tissue. I'm really stuck on what's best CPT per his report.

1. Incision and debridement with irrigation right ankle. Abscess depth approximately 5 cm, length approximately 12 cm with approximately 8 cm width.

The right lower extremity was prepped and draped sterilely. The tourniquet was inflated without exsanguinating the right ankle. The patient had an area of what appeared to be a possible spider bite. Pus was draining out as well as from the small incision made yesterday. The incision was then elongated. There was significant purulence present. The purulence was drained. The wound was copiously debrided removing all necrotic and fatty tissue that appeared to be infected with a curette. The measurements of the abscess were previously stated. At this point in time, the wound was copiously irrigated with 3 liters of normal saline under pulsatile lavage. The patient did have significant swelling of her foot and medial aspect. Two 2 cm incisions were made, one on the dorsum of the right foot and one medially to ensure that there was no purulence which there was not. These were then closed with 0-Prolene suture after being irrigated. The incision laterally was then irrigated with a total of 6 more liters of normal saline under pulsatile lavage. At this point in time, the central area of necrosis where it appeared to be some sort of bug bite was excised. The very proximal and distal aspect of the wound was then closed. A wound vac was then placed. A sterile dressing was placed as well as a splint.