KBean2018
Guru
I am reviewing the below procedure, I am leaning towards 19328-rt, and 13101 for irrigation and debridement, since it went down to the tissue? Any help is appreciated. thank you
Pre-op Diagnosis:
Ruptured silicone breast implant, subsequent encounter [T85.49XD]
Wound dehiscence, surgical, subsequent encounter [T81.31XD]
Breast infection [N61.0]
Post-op Diagnosis:
same
Procedure:
Post-Op Diagnosis Codes:
* Ruptured silicone breast implant, subsequent encounter [T85.49XD]
* Wound dehiscence, surgical, subsequent encounter [T81.31XD]
* Breast infection [N61.0]
Procedure(s):
IRRIGATION & DEBRIDEMENT BREAST WOUND / ABSCESS
BREAST IMPLANT REMOVAL
Her right JP drain is prepped into the surgical field. Of note there was a 5 cm long dehiscence along the vertical limb of her incision extending to her IMF. Cultures were taken of the fluid found within the breast cavity after removing her saline implant. There was no gross purulence noted only some murky yellow fluid without an odor. Using a 15 blade scalpel an elliptical incision was made along her prior vertical mastopexy incision measuring 9 cm in length in order to find healthy bleeding skin edges on either side of the dehiscence. As was seen 1 week ago there was additional necrotic subcutaneous fat and breast tissue found today which was debrided. 3 L of normal saline was then lavaged within the right breast cavity. The incision was closed in layers using 2-0 Vicryl suture in the dermis and interrupted 3-0 nylon mattress sutures to reapproximate the skin edges loosely. A prevena incisional wound VAC was placed over the incision to facilitate healing. The patient was awoken from anesthesia without complication and transferred to the recovery room in stable condition. At the end of the case all the needle, sponge and instrument counts were correct x 2 and I was present for the entire case.
Pre-op Diagnosis:
Ruptured silicone breast implant, subsequent encounter [T85.49XD]
Wound dehiscence, surgical, subsequent encounter [T81.31XD]
Breast infection [N61.0]
Post-op Diagnosis:
same
Procedure:
Post-Op Diagnosis Codes:
* Ruptured silicone breast implant, subsequent encounter [T85.49XD]
* Wound dehiscence, surgical, subsequent encounter [T81.31XD]
* Breast infection [N61.0]
Procedure(s):
IRRIGATION & DEBRIDEMENT BREAST WOUND / ABSCESS
BREAST IMPLANT REMOVAL
Her right JP drain is prepped into the surgical field. Of note there was a 5 cm long dehiscence along the vertical limb of her incision extending to her IMF. Cultures were taken of the fluid found within the breast cavity after removing her saline implant. There was no gross purulence noted only some murky yellow fluid without an odor. Using a 15 blade scalpel an elliptical incision was made along her prior vertical mastopexy incision measuring 9 cm in length in order to find healthy bleeding skin edges on either side of the dehiscence. As was seen 1 week ago there was additional necrotic subcutaneous fat and breast tissue found today which was debrided. 3 L of normal saline was then lavaged within the right breast cavity. The incision was closed in layers using 2-0 Vicryl suture in the dermis and interrupted 3-0 nylon mattress sutures to reapproximate the skin edges loosely. A prevena incisional wound VAC was placed over the incision to facilitate healing. The patient was awoken from anesthesia without complication and transferred to the recovery room in stable condition. At the end of the case all the needle, sponge and instrument counts were correct x 2 and I was present for the entire case.