nc_coder
Expert
See the op note below. This is excision not debridement. We are having som issues finding a code for this. Thank you.
PREOPERATIVE DIAGNOSES:
1. Sinus tract of the right hip, now about a year or so status post right hip replacement.
POSTOPERATIVE DIAGNOSES:
1. Sinus tract of the right hip with no apparent involvement of the prosthetic right hip.
OPERATIVE PROCEDURE PERFORMED:
1. Excision sinus tract of the right hip.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and after administration of general anesthesia, the patient's right hip area was prepped and draped in the usual sterile fashion. External opening of the sinus tract was then probed with a metal probe and this was left in place. Elliptical incisions were then made to contain the sinus tract as it went down to what appeared to be fascia and then this sinus tract was submitted to pathology. However, we enlarged the incision because there appeared to be a pocket that we entered, which was consistent with the findings on MRI. This pocket, however, did not communicate with the prosthetic in the right hip to our observation and to probing, but we made sure that its full extent was completely opened. We did not note any foreign material in terms of suture in the wound either, and assured that we were in clean, healthy and viable tissue. We then generously irrigated the wound. The wound was then packed with wet-to-dry dressings. The patient tolerated the procedure well. Bleeding was controlled using electrocautery and the wound was not closed. He tolerated the procedure without any problems or complications and was admitted to the recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSES:
1. Sinus tract of the right hip, now about a year or so status post right hip replacement.
POSTOPERATIVE DIAGNOSES:
1. Sinus tract of the right hip with no apparent involvement of the prosthetic right hip.
OPERATIVE PROCEDURE PERFORMED:
1. Excision sinus tract of the right hip.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and after administration of general anesthesia, the patient's right hip area was prepped and draped in the usual sterile fashion. External opening of the sinus tract was then probed with a metal probe and this was left in place. Elliptical incisions were then made to contain the sinus tract as it went down to what appeared to be fascia and then this sinus tract was submitted to pathology. However, we enlarged the incision because there appeared to be a pocket that we entered, which was consistent with the findings on MRI. This pocket, however, did not communicate with the prosthetic in the right hip to our observation and to probing, but we made sure that its full extent was completely opened. We did not note any foreign material in terms of suture in the wound either, and assured that we were in clean, healthy and viable tissue. We then generously irrigated the wound. The wound was then packed with wet-to-dry dressings. The patient tolerated the procedure well. Bleeding was controlled using electrocautery and the wound was not closed. He tolerated the procedure without any problems or complications and was admitted to the recovery room in satisfactory condition.