Good Morning,
I was hoping to get some feedback on the following procedure. I am stumped and not sure what code to use. (CPT 20102-5 or 49000-52?)
Postop Dx: Enterocutaneous fistula secondary to foreign body
Name of Operation: Examination under anesthesia and probing of enterocutaneous fistula
Anesthesia: Conscious sedation
Indication for Procedure: Pt was developing a serous discharge from his abdominal wound that had previously only been chronically draining infected material from what appeared to be a sinus tract. CT scan had confirmed the presence of an enterocutaneous fistula. Decision was made to bring the pt to the OR to see if we could remove any mesh that might still be responsible for initiating the enterocutaneous fistula.
Description of Operation: Under conscious sedation, the abdomen was prepped and draped. An appropriate time out was performed prior to the procedure. Pt was already on broad spectrum antibiotics.
After draping the field, we carefully probed the wound with Q-tips. The wound appeared to be quite deep and in one area where the enterocutaneous fistula appeared to be there was no discernible mesh or suture material visible that could explain any foreign body having eroded through the bowel wall.
Upon gentle probing, it appeared that there was some bleeding easily stirred up probably with some underlying granulation tissue. After probing the wound and discovering no material to be removed easily, procedure was terminated and sterile dressing was applied back to the wound.
I was hoping to get some feedback on the following procedure. I am stumped and not sure what code to use. (CPT 20102-5 or 49000-52?)
Postop Dx: Enterocutaneous fistula secondary to foreign body
Name of Operation: Examination under anesthesia and probing of enterocutaneous fistula
Anesthesia: Conscious sedation
Indication for Procedure: Pt was developing a serous discharge from his abdominal wound that had previously only been chronically draining infected material from what appeared to be a sinus tract. CT scan had confirmed the presence of an enterocutaneous fistula. Decision was made to bring the pt to the OR to see if we could remove any mesh that might still be responsible for initiating the enterocutaneous fistula.
Description of Operation: Under conscious sedation, the abdomen was prepped and draped. An appropriate time out was performed prior to the procedure. Pt was already on broad spectrum antibiotics.
After draping the field, we carefully probed the wound with Q-tips. The wound appeared to be quite deep and in one area where the enterocutaneous fistula appeared to be there was no discernible mesh or suture material visible that could explain any foreign body having eroded through the bowel wall.
Upon gentle probing, it appeared that there was some bleeding easily stirred up probably with some underlying granulation tissue. After probing the wound and discovering no material to be removed easily, procedure was terminated and sterile dressing was applied back to the wound.