trinalankford
Guru
Struggling with whether I can code the scrotal exploration or just the wound repair....
"Exam under anesthesia revealed that this was not a deeply penetrating injury. Using a Pean we probed and found there was an obvious tract from left anterior to right lower lateral. We left the Pean in for retraction. Wound was irrigated. We evacuated and expressed clot and then irrigated again. We brought a Penrose through the incision to retract to inspect the interior laceration and palpate the tract, ensuring no FB material, of which there was none. The previous bleeding had stopped, and there was only superficial coagulation required for hemostasis. The 4-cm exit wound did not require debridement, but I placed several sutures to tighten up the exit wound to ensure contents did not extrude and left a drain in place."
55110 - Scrotal exploration (I'm under the assumption that this requires the MD to make an incision and not go through an existing wound? but cannot really substantiate this on line)
12042 - Intermediate repair, genitalia, 2.6-7.5 cm
*OR*
12002 - Simple repair due to no FB and no debridement necessary?
Thank you!
"Exam under anesthesia revealed that this was not a deeply penetrating injury. Using a Pean we probed and found there was an obvious tract from left anterior to right lower lateral. We left the Pean in for retraction. Wound was irrigated. We evacuated and expressed clot and then irrigated again. We brought a Penrose through the incision to retract to inspect the interior laceration and palpate the tract, ensuring no FB material, of which there was none. The previous bleeding had stopped, and there was only superficial coagulation required for hemostasis. The 4-cm exit wound did not require debridement, but I placed several sutures to tighten up the exit wound to ensure contents did not extrude and left a drain in place."
55110 - Scrotal exploration (I'm under the assumption that this requires the MD to make an incision and not go through an existing wound? but cannot really substantiate this on line)
12042 - Intermediate repair, genitalia, 2.6-7.5 cm
*OR*
12002 - Simple repair due to no FB and no debridement necessary?
Thank you!