Right above the knee amputation revision with sinus tract excision including skin ellipse (6cm x 2cm)
Pt developed a skin opening in the right above knee amputation stump. Sinus tract has previously healed but appears to be recurring.
The sinus tract opening was inspected and spread open. No purulence or discharge was noted. Next, a transverse skin ellipse measuring 6 cm by 2 cm wide including the sinus tract in the center was marked. This was followed by an incision along the skin marking. SubQ dissection with electrocautery was performed until the deep fascia covering the muscle was encountered, an ellipse of fascial layer was excised enbloc with the sinus tract. Hemostasis was secured with cauterization of small bleeding vessels. The muscle is contractile and viable and the the bone was properly covered with healthy tissue and left untouched. No signs of deep tissue infection was encountered. The fascia covering the muscle was healthy. I started the wound closure with simple stitches...etc.
How would you code this? Thanks!!
Pt developed a skin opening in the right above knee amputation stump. Sinus tract has previously healed but appears to be recurring.
The sinus tract opening was inspected and spread open. No purulence or discharge was noted. Next, a transverse skin ellipse measuring 6 cm by 2 cm wide including the sinus tract in the center was marked. This was followed by an incision along the skin marking. SubQ dissection with electrocautery was performed until the deep fascia covering the muscle was encountered, an ellipse of fascial layer was excised enbloc with the sinus tract. Hemostasis was secured with cauterization of small bleeding vessels. The muscle is contractile and viable and the the bone was properly covered with healthy tissue and left untouched. No signs of deep tissue infection was encountered. The fascia covering the muscle was healthy. I started the wound closure with simple stitches...etc.
How would you code this? Thanks!!