what CPT code would be used here:
History of Present Illness: Patient is here today for wound check. Patient had called in earlier stating that his wound was closing in the treatment room was having difficulty packing his abscess. Patient would like this opening seen to today's so he can continue with the packing and healing to prevent recurrence
Plan:
Wound opening was modified today, see below
Continue with daily dressing changes as previously established. Recommend tail of packing be adjusted to lay in the distal aspect of the opening to prevent new incision from closing
Incision Procedure Note
Indications: premature closure of abscess
Location: midline lumbo/sacral area
Anesthesia: Lidocaine 1% with epinephrine
Procedure details:
The risks, benefits, indications, potential complications, and alternatives were explained to the patient and informed consent obtained.
Current packing was removed. The lesion and surrounding area was prepped alcohol. Anesthesia was confirmed. A scalpel was used sharply incise down perpendicular to the skin edge at the distal edge of the current opening. The opening was then extended 4-5 mm for a total new length of 10 mm. Area was irrigated with normal saline then repacked and dressed.
Condition: Stable
Complications: None
Any input/help would be greatly appreciated.
History of Present Illness: Patient is here today for wound check. Patient had called in earlier stating that his wound was closing in the treatment room was having difficulty packing his abscess. Patient would like this opening seen to today's so he can continue with the packing and healing to prevent recurrence
Plan:
Wound opening was modified today, see below
Continue with daily dressing changes as previously established. Recommend tail of packing be adjusted to lay in the distal aspect of the opening to prevent new incision from closing
Incision Procedure Note
Indications: premature closure of abscess
Location: midline lumbo/sacral area
Anesthesia: Lidocaine 1% with epinephrine
Procedure details:
The risks, benefits, indications, potential complications, and alternatives were explained to the patient and informed consent obtained.
Current packing was removed. The lesion and surrounding area was prepped alcohol. Anesthesia was confirmed. A scalpel was used sharply incise down perpendicular to the skin edge at the distal edge of the current opening. The opening was then extended 4-5 mm for a total new length of 10 mm. Area was irrigated with normal saline then repacked and dressed.
Condition: Stable
Complications: None
Any input/help would be greatly appreciated.