op note need opinions please

trose45116

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hi, can i get some opinions on what you all would code from this? would you code for a removal and reimplantation of the spinal stimulator device or would this be included in flap reconstruction.


PREOPERATIVE DIAGNOSIS: Posterior cervical pain stimulator device wound
recurrent.
POSTOPERATIVE DIAGNOSIS: Posterior cervical pain stimulator device wound
recurrent.
PROCEDURE PERFORMED: 1. Excision of open posterior cervical wound
12cm2.
2. Removal and reimplantation of spinal
stimulator device.
3. LEFT lateral neck fasciocutaneous tissue
composite reconstruction 20 cm2.
4. RIGHT lateral neck fasciocutaneous tissue
composite reconstruction 20 cm2.
5. 8 cm complex closure of open wound of
neck.



DESCRIPTION OF PROCEDURE: After the patient was brought to the operating room and
carefully positioned on the operating table and safely and effectively secured to the table and padded in all
areas to avoid any injury to them the patient was then safely and effectively anesthetized. Patient was
kept warm throughout the procedure and monitored carefully as well by the anesthesiologist.
The patient was positioned with the LEFT side up and the RIGHT side down and secured to the table
safely.
The operative areas were then prepared with antiseptic thoroughly and draped sterilely.
The operative areas were then carefully injected with 0.25% Marcaine with epinephrine for intraoperative
hemostasis and postoperative pain control as well.
This open wound of the midline posterior cervical soft tissue was excised with a very small 0.5 cm3
abscess in an extramarginal fashion approximately 12 cm2 removing all the inflammatory exudate of the
skin and subcutaneous tissue superficial and deep fascia, muscle and the devascularized soft tissue in this
area utilizing sharp instruments including scalpel, sharp curettage, scissors, cautery and double action sharp
rongeurs and then widely and copiously irrigating this with Betadine throughout the excision in preparation
for soft tissue reconstruction. In doing so a secondary defect was created in addition to the primary defect
created by the excision of the wound to allow local transposition of soft tissue in a favorable way for
reconstruction of the wound to minimize the contour defect and the deformity and distracting nature of the
defect as well as optimizing the vascular inflow and venous drainage to the soft tissue ultimately used for
reconstruction. No abscess was seen. The eschar was removed in its entirety. With careful dissection this
stimulator paddle approximate 4 cm long was then withdrawn from its long narrow pathway into which
there was this inflammatory material that appeared to be the nidus of infection. This entire tract was then
extirpated of its soft tissue inflammatory element back to well vascularized uninjured tissue. This track
was then irrigated with Betadine and packed with vancomycin. The paddle itself and the base of the wire
were irrigated copiously with I3etadine throughout the procedure to sterilize this as well. There are other
small elements of wire that did not appear to be involved in this infectious process as most of the coil the
wire well incorporated of the scar over time. The tissue removed from the depth of this wound was then
sent to the laboratory for quantitative culture and sensitivity. I inquired whether the patient had any
ALLERGY to vancotnycin and no allergy is known or documented by the family or patient to this

medication. The wound was then also treated internally with lyophilized vancomycin powder placed into
the depths of the wound on all surfaces for ftjrther antisepsis locally in the deep tissue planes prior to
closure of the wound.
An extensive remobilization re-elevation and further transposition of a fasciocutaneous flap tissue
composite was then elevated on the LEFT lateral aspect of the neck which included dissection and
counter incisions of the deep fascia extensively 20 cm2 including detachment of the fascia and skin from
its origin and inserted deep structures and portions of the proximal and distal elements of the musculature.
This flap is a Type V classification flap. This allowed the tissue composite flap to be advanced, transposed
and rotated 20 cm2 with preservation and respect of the flap’s axial based upon the posterior cervical
artery and vein perforating vessels and secondary perforating blood supply after identifying and avoiding
the ingress and egress posterior cervical artery and vein perforating vessels throughout the dissection. No
innervation was identified or was relevant to this tissue advancement as a neurotized flap was not
indicated for the reconstruction however the motor nerves to the musculature itself were preserved. The
overlying skin and subcutaneous tissue was preserved with its cutaneous vascular perforators from the
fascial portion of this advancement flap tissue composite to create the fasciocutaneous flap tissue
composite for reconstruction of this open wound. This mass of the tissue composite flap and overlying soft
tissue was mobilized and transposed 20cm2 to obliterate the deep space created by the open wound and
the underlying strucfttres which required well vascularized soft tissue coverage for ultimate reconstruction
and healing of this complicated deep wound. This soft tissue composite flap was then inset within its arc of
rotation.
An extensive remobilization re-elevation and further transposition of a fasciocutaneous flap tissue
composite was then elevated on the RIGHT lateral aspect of the neck which included dissection and
counter incisions of the deep fascia extensively 20 cm2 including detachment of the fascia and skin from
its origin and inserted deep structures and portions of the proximal and distal elements of the musculature.
This flap is a Type \7 classification flap. This allowed the tissue composite flap to be advanced, transposed
and rotated 20cm2 with preservation and respect of the flap’s axial based upon the posterior cervical
artery and vein perforating vessels and secondary perforating blood supply after idenri1’ing and avoiding
the ingress and egress posterior cervical artery and vein perforating vessels throughout the dissection. No
innervation was identified or was relevant to this tissue advancement as a neurotized flap was not
indicated for the reconstruction however the motor nerves to the musculature itself were preserved. The
overlying skin and subcutaneous tissue was preserved with its cutaneous vascular perforators from the
fascial portion of this advancement flap tissue composite to create the fasciocutaneous flap tissue
composite for reconstruction of this open wound. This mass of the tissue composite flap and overlying soft
tissue was mobilized and transposed 20 cm2 to obliterate the deep space created by the open wound and
the underlying structures which required well vascularized soft tissue coverage for ultimate reconstruction
and healing ofthis complicated deep wound. This soft tissue composite flap was then inset within its arc of
rotation.

The 2 separate 20 cm2 tissue composites were then transposed 20 cm2 and imbricated across the midline
of the open wound of the posterior cervical wound 12 cm2 closing the primary and secondary defects
created by the original wound and the mobilization and transpositions utilizing 2-0 Monocryl plus inverted
simple suture materiai every 2-3 mm for a watertight well vascularized soft tissue closure overlying the
deep tissues creating an accurately reconstructed tensionless closure over the posterior cervical wound.
The wound was then closed further at the more superficial elements approximately 8 cm using a complex
multilayer running 4-0 nylon to the skin followed and interposed by 4-0 nylon wider longer simple suture
material for further security the closure of the wound every 4mm.
The wound was then sealed with dermal glue and Steri-Strips.
The patient did well and was brought to the recovery area in good condition having tolerated procedure
well. No complications occurred during or after the operation. The patient was stable in the PACU.
All postoperative orders are written extensively for the patient for their immediate and long-term care.
I spoke with her mother in detail postoperatively and she was very happy with her care.
Prescriptions, postoperative orders, care instructions and follow-up appointment had already been given to
the patient previously. She did very well the recovery area. She is happy with her care. Were delighted to
help her today.
 

RyanRaichCPC

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Local Chapter Officer
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I don't think that you can bill again for the implantation since the same device is being used. The implantation code actually has the cost of the device built in to it.
 
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