Dr. called this an exploration of abdominal wound for a draining cutaneous sinus tract. I'm not sure what to code this as and would appreciate any thoughts you might have. Here is the op note..
After operative anesthesia and site was verified, the patient
was taken to the operating room and placed in supine position on the
operating table. General endotracheal anesthesia instituted. The abdomen
was prepped and draped sterilely. The site of previous sinus tract was
injected with local anesthetic, incision made there, carried down through
the previous sinus tract scar is identified and excised using surgical
diathermy. This was taken down to the base of the fascia. There was no
further residual remaining. It is unclear whether there was any suture
material in that fistula tract. The area was irrigated with sterile
solution _____ further no other material left _____ could be visualized.
The wound was irrigated with sterile solution, hemostasis achieved with
surgical diathermy _____ was closed with interrupted 4-0 nylon sutures at
the skin level. Sterile dressing applied. The patient was awakened,
extubated, transferred to recovery having tolerated the procedure well.
After operative anesthesia and site was verified, the patient
was taken to the operating room and placed in supine position on the
operating table. General endotracheal anesthesia instituted. The abdomen
was prepped and draped sterilely. The site of previous sinus tract was
injected with local anesthetic, incision made there, carried down through
the previous sinus tract scar is identified and excised using surgical
diathermy. This was taken down to the base of the fascia. There was no
further residual remaining. It is unclear whether there was any suture
material in that fistula tract. The area was irrigated with sterile
solution _____ further no other material left _____ could be visualized.
The wound was irrigated with sterile solution, hemostasis achieved with
surgical diathermy _____ was closed with interrupted 4-0 nylon sutures at
the skin level. Sterile dressing applied. The patient was awakened,
extubated, transferred to recovery having tolerated the procedure well.