Secondary I&D, please help!!!

katiejeanne

Guest
Messages
49
Best answers
0
An I&D of an abscess of the left foot was performed 2 days before the following surgery took place. The 2nd procedure was planned. I was going to code 13160-58 for secondary closure, which would include the debridement but the sinus tract thing is throwing me off. Do I need to code any ICD-9 codes or CPT-4 codes for the sinus tract being there? He doesn't really say that he excised the tract. He states the procedure is an I&D but I don't see that in the report, just the debridement and secondary closure...So is 13160-58 appropriate in this case? Any opinions would be greatly appreciated!! Thank you!
OP Report:

PREOPERATIVE DIAGNOSES:
1) Ulceration left foot
2) Abscess/cellulitis left foot
3) Previous incision and drainage left foot.
POSTOPERATIVE DIAGNOSES: Same
OPERATIVE PROCEDURE: Incision and drainage with secondary closure left foot.
PATHOLOGY: Cultures were taken aerobic and anaerobic
ANESTHESIA: Local, MAC
HEMOSTASIS: None
INJECTABLES PREOPERATIVELY: Approximately 13 cc 1:1 mix of 1% lidocaine and 0.5% Marcaine plain.
MATERIALS: ¼-inch iodoform gauze packing
COMPLICATIONS: None
CONDITION: The patient tolerated the procedure and anesthesia well. Capillary refill time less than 3 seconds to all digits to her left foot.
DESCRIPTION OF OPERATION: The patient was brought to the operating field and placed on the operating table in the supine position. After administration of sedation, the left foot was anesthetized using the above mixture. A well padded ankle tourniquet was applied but was not used. The foot and ankle were properly prepped and draped using aseptic fashion.
At this time attention was directed to the incision and previous abscess noted between her fourth and fifth digits. Good granular tissue was noted. There was still some maceration noted interdigitally though. At this time, the sutures were removed and the incision was excised and freshened. Adequate bleeding was noted. It was still noted there was a sinus tract approximately 1-2 cm noted plantarly from the incisional area. All redundant skin was also removed and the incision area was debrided with a #15 blade. Prior to the area being flushed, cultures were taken. The area was then flushed. The area appeared to be clean. The sinus tract was again packed with iodoform gauze packing. The incision layer was reapproximated with 3-0 nylon in simple interrupted type fashion. Sterile dressing was applied. The patient was taken to the recover room where all orders and instructions were given.
 
Messages
4,466
Location
Milwaukee WI
Best answers
0
I would use 10061

I would use 10061. I checked to see if there was a musculoskeletal code that would apply, but the closes I came up with was 28001 ... and I don't see evidence of his going into the bursa at all.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Top