jeskla
Networker
Would someone please help me with this op note? The doc has irrigation and debridement as the procedure, but I am not seeing that in the body of the note. It looks like he just punctured the bursa with a needle and irrigated it. Would this just be 20605-LT since there was no incision?
ASSESSMENT
Left septic olecranon bursitis.
PLAN
Irrigation and debridement.
After consent was obtained and sterile prep, an 18-gauge needle was
introduced into the olecranon bursa. The olecranon bursa was then
insufflated with 10 mL of 1% lidocaine to effect local anesthesia. Following
this, the bursa was repeatedly irrigated with sterile saline, a total of 100
mL was irrigated sequentially in and out of joint in 20 mL aliquots. With
initial needle penetration, 3 mL of purulent fluid were sent for culture.
Once irrigation was complete, the needle was withdrawn. The patient
tolerated the procedure well with no complications.
ASSESSMENT
Left septic olecranon bursitis.
PLAN
Irrigation and debridement.
After consent was obtained and sterile prep, an 18-gauge needle was
introduced into the olecranon bursa. The olecranon bursa was then
insufflated with 10 mL of 1% lidocaine to effect local anesthesia. Following
this, the bursa was repeatedly irrigated with sterile saline, a total of 100
mL was irrigated sequentially in and out of joint in 20 mL aliquots. With
initial needle penetration, 3 mL of purulent fluid were sent for culture.
Once irrigation was complete, the needle was withdrawn. The patient
tolerated the procedure well with no complications.
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