Trendale
Guru
Hello,
Can someone help me code the following report: The physician submitted code 43659
Thanks!
TE: 08/29/09
PREOPERATIVE DIAGNOSIS: Infected gastric band port.
POSTOPERATIVE DIAGNOSIS: Infected gastric band port.
NAME OF OPERATION: Removal of infected gastric band port.
ANESTHESIA: General anesthesia with LMA.
ESTIMATED BLOOD LOSS: Minimal.
INDICATION FOR THE PROCEDURE: The patient is a 49-year-old female who
had a gastric band revised approximately a month ago. In the last 3
to 4 weeks, she has been complaining of excruciating pain at the site
of the port with intermittent redness and erythema, ??<__________>.
We obtained a CT which shows some fluid around and inflammation around
the port consistent with possible infection. She was thus taken to
the operating room for removal.
DESCRIPTION OF OPERATION: She was positioned on the operating table
in supine fashion. After induction of anesthesia with LMA, the
abdomen was prepped and draped in the usual sterile fashion. Marcaine
0.5% plain was used to infiltrate the area line overlying this
palpable port. A small incision was made and dissection carried down
through the subcutaneous tissue. Appropriate retractors were placed
and slowly we came up to the area where the port was found. There
were 2-0 Ethibond stitches holding the port to the anterior abdominal
wall that were cut. We were now able to bring the port outside the
incision. We now cut the port and let the rest of the catheter fall
back into abdominal cavity. We now irrigated the area with antibiotic
solution. Prior to this, we have sent for cultures and sensitivity of
the port and port sites. We finished irrigating with antibiotic
solution and performed closure. Closure was done in 2 layers by
approximating subcutaneous tissue with 3-0 Monocryl, then the skin was
closed with a running 4-0 Monocryl in subcuticular fashion. Patient
tolerated procedure quite well. She was then taken to recovery in
stable condition.
Can someone help me code the following report: The physician submitted code 43659
Thanks!TE: 08/29/09
PREOPERATIVE DIAGNOSIS: Infected gastric band port.
POSTOPERATIVE DIAGNOSIS: Infected gastric band port.
NAME OF OPERATION: Removal of infected gastric band port.
ANESTHESIA: General anesthesia with LMA.
ESTIMATED BLOOD LOSS: Minimal.
INDICATION FOR THE PROCEDURE: The patient is a 49-year-old female who
had a gastric band revised approximately a month ago. In the last 3
to 4 weeks, she has been complaining of excruciating pain at the site
of the port with intermittent redness and erythema, ??<__________>.
We obtained a CT which shows some fluid around and inflammation around
the port consistent with possible infection. She was thus taken to
the operating room for removal.
DESCRIPTION OF OPERATION: She was positioned on the operating table
in supine fashion. After induction of anesthesia with LMA, the
abdomen was prepped and draped in the usual sterile fashion. Marcaine
0.5% plain was used to infiltrate the area line overlying this
palpable port. A small incision was made and dissection carried down
through the subcutaneous tissue. Appropriate retractors were placed
and slowly we came up to the area where the port was found. There
were 2-0 Ethibond stitches holding the port to the anterior abdominal
wall that were cut. We were now able to bring the port outside the
incision. We now cut the port and let the rest of the catheter fall
back into abdominal cavity. We now irrigated the area with antibiotic
solution. Prior to this, we have sent for cultures and sensitivity of
the port and port sites. We finished irrigating with antibiotic
solution and performed closure. Closure was done in 2 layers by
approximating subcutaneous tissue with 3-0 Monocryl, then the skin was
closed with a running 4-0 Monocryl in subcuticular fashion. Patient
tolerated procedure quite well. She was then taken to recovery in
stable condition.
