slc112071
Networker
Could someone please help me out with the below report? Please give me your input on if this is still included in the primary surgery or if it is billable. If it is billable, what CPT would you use?
PREOPERATIVE DIAGNOSIS: Retained surgical foreign body (JP drain).
POSTOPERATIVE DIAGNOSIS: Retained surgical foreign body (JP drain).
PROCEDURE: Removal of JP drain.
BRIEF CLINICAL NOTE: The patient underwent an L2-3 reexploration laminectomy diskectomy last week. After that surgery I placed a JP drain. When I attempted to withdraw the drain yesterday it was obviously anchored deep in the tissues and could not be withdrawn. He is therefore being brought down to the operating room for proper prep and then removal of the drain.
PROCEDURE: He was brought into the operating room, given MAC analgesia, and rolled prone. His back was prepped and draped into a sterile field and local anesthetic used to anesthetize the skin. I removed the bottom three cutaneous stitches and then explored in the subcutaneous space and found the stitch that was anchoring the drain into the subcutaneous. I simply clipped this fascial stitch and withdrew the drain quite easily, then replaced a fascial stitch and reclosed the skin with a mattress suture. No blood loss. He tolerated well and was transported to recovery room in stable condition.
PREOPERATIVE DIAGNOSIS: Retained surgical foreign body (JP drain).
POSTOPERATIVE DIAGNOSIS: Retained surgical foreign body (JP drain).
PROCEDURE: Removal of JP drain.
BRIEF CLINICAL NOTE: The patient underwent an L2-3 reexploration laminectomy diskectomy last week. After that surgery I placed a JP drain. When I attempted to withdraw the drain yesterday it was obviously anchored deep in the tissues and could not be withdrawn. He is therefore being brought down to the operating room for proper prep and then removal of the drain.
PROCEDURE: He was brought into the operating room, given MAC analgesia, and rolled prone. His back was prepped and draped into a sterile field and local anesthetic used to anesthetize the skin. I removed the bottom three cutaneous stitches and then explored in the subcutaneous space and found the stitch that was anchoring the drain into the subcutaneous. I simply clipped this fascial stitch and withdrew the drain quite easily, then replaced a fascial stitch and reclosed the skin with a mattress suture. No blood loss. He tolerated well and was transported to recovery room in stable condition.