Scrotal Wound Exploration

toria11

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Clearwater, FL
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Any suggestions on how to code this post op scrotal wound exploration? Any help is appreciated!

Preop Diagnosis: Scrotal wound infection

Procedure Performed: Exploration of scrotal wound

Indications: Patient had a left hydrocelectomy on October 4th. Over the last several days wound opened and developed erythema of his scrotum. Presents for further exploration.

Findings: Scrotal wound is open but testicle appears normal and no obvious purulence palpated or found. Right hemiscrotim is edematous. Penis appears mottled and areas a crust around the urethral meatus. Sixteen French Foley catheter was placed and 400mL of amber urine was drained. Urine was sent for culture.

Procedure: Patient brought to the cystoscopy suite and after a proper time-out was performed the patient was administered genereal anesthesia was palced in the supine position and prepped and draped in usual sterile fashion. After noticing the modeling of the penis the crust around the meatus a 16 French Foley catheter was passed per urethra into the bladder without problem. Four hundred mL was drained and urine was sent for culture. Then the wound was explored and irrigated copiously with gentamicin saline solution. Findings were stated above. Then using 2 inch iodoform gauze the wound was packed covered by what dry dressings and then a scrotal support. Patient sent to recovery in stable condition.
 
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