apoland
Networker
Hello,
We had a case where our provider intended an I&D of an eyelid abscess. At the time of surgery the abscess had enlarged significantly and the material was able to be curretted out via an open punctum. There was no surgical incision or needle aspiration in order to bill 10060/10160. My suggestion is 12011 as the wound was irrigated and closed with 2 simple sutures. I am curious what others think. I appreciate any assistance
Report: Patient was positively identified in the preoperative holding area and taken to the operating theater. * underwent general anesthesia via mask induction and IV placement. * was intubated with the LMA uneventfully. * right eye was prepped and draped in the usual sterile fashion with dilute Betadine. * eye protected with Tegaderm. We performed the operative timeout confirming the patient, site, site of surgery. I then began with injecting local anesthesia, using a 1% lidocaine with epinephrine approximately 4 cc were used. There was an open area on the punctum that was already draining and through this I used a curette to evacuate the material inside the cyst wall a copious amount of thick seropurulent and calcified material was expressed. This was sent for pathology, Gram stain aerobic anaerobic cultures, acid-fast bacilli and fungal cultures. Once the entirety of the abscess pocket was evacuated and there was no further material able to be expressed the wound was copiously irrigated with dilute Betadine. A Bovie cautery was used to perform hemostasis of the cavity. I then placed 2 interrupted 5-0 fast gut sutures to reapproximate the edges of the open area. The eye was irrigated with basic salt solution and ophthalmic safe bacitracin was placed over the wound itself. The wound was dressed with gauze and Tegaderm dressing. Patient was extubated in excellent condition and returned to the postoperative recovery area. All sponge and instrument counts were correct at the end of the case.
We had a case where our provider intended an I&D of an eyelid abscess. At the time of surgery the abscess had enlarged significantly and the material was able to be curretted out via an open punctum. There was no surgical incision or needle aspiration in order to bill 10060/10160. My suggestion is 12011 as the wound was irrigated and closed with 2 simple sutures. I am curious what others think. I appreciate any assistance
Report: Patient was positively identified in the preoperative holding area and taken to the operating theater. * underwent general anesthesia via mask induction and IV placement. * was intubated with the LMA uneventfully. * right eye was prepped and draped in the usual sterile fashion with dilute Betadine. * eye protected with Tegaderm. We performed the operative timeout confirming the patient, site, site of surgery. I then began with injecting local anesthesia, using a 1% lidocaine with epinephrine approximately 4 cc were used. There was an open area on the punctum that was already draining and through this I used a curette to evacuate the material inside the cyst wall a copious amount of thick seropurulent and calcified material was expressed. This was sent for pathology, Gram stain aerobic anaerobic cultures, acid-fast bacilli and fungal cultures. Once the entirety of the abscess pocket was evacuated and there was no further material able to be expressed the wound was copiously irrigated with dilute Betadine. A Bovie cautery was used to perform hemostasis of the cavity. I then placed 2 interrupted 5-0 fast gut sutures to reapproximate the edges of the open area. The eye was irrigated with basic salt solution and ophthalmic safe bacitracin was placed over the wound itself. The wound was dressed with gauze and Tegaderm dressing. Patient was extubated in excellent condition and returned to the postoperative recovery area. All sponge and instrument counts were correct at the end of the case.