Bea024
New
Hoping for some help with the report below, our surgeon is billing 21627 (sternal debridement) but it does not seem like the correct code for this to me.
PROCEDURE PERFORMED:
Incision and drainage of sternoclavicular joint abscess with clavicular head
debridement and placement of wound VAC.
INDICATIONS FOR PROCEDURE:
The patient is a 68-year-old male with multiple medical problems who presented
with a painful right sternoclavicular joint. The patient on CT scan was found
to have abnormalities consistent with an abscess.
FINDINGS:
The patient had an area of destruction of the clavicular head with abscess of
the sternoclavicular joint.
DESCRIPTION OF PROCEDURE:
Under sterile and controlled conditions, the patient was prepped and draped in
usual sterile fashion. An incision was made over the sternoclavicular joint
and it was noticed the patient had a cavity, which was entered. The patient
had a cloudy purulent fluid. This was drained. Cultures were obtained. It
was noticed the patient had partial destruction of the head of the clavicle.
At this point in time by means of a curette and a rongeur, the head of the
clavicle was partially debrided. The cavity was irrigated thoroughly with
irrigator solution. At the completion of the procedure, a wound VAC sponge
was tailored and placed in the wound. The wound VAC was placed to 125 mmHg
continuous pressure. The patient is to be monitored in PACU.
PROCEDURE PERFORMED:
Incision and drainage of sternoclavicular joint abscess with clavicular head
debridement and placement of wound VAC.
INDICATIONS FOR PROCEDURE:
The patient is a 68-year-old male with multiple medical problems who presented
with a painful right sternoclavicular joint. The patient on CT scan was found
to have abnormalities consistent with an abscess.
FINDINGS:
The patient had an area of destruction of the clavicular head with abscess of
the sternoclavicular joint.
DESCRIPTION OF PROCEDURE:
Under sterile and controlled conditions, the patient was prepped and draped in
usual sterile fashion. An incision was made over the sternoclavicular joint
and it was noticed the patient had a cavity, which was entered. The patient
had a cloudy purulent fluid. This was drained. Cultures were obtained. It
was noticed the patient had partial destruction of the head of the clavicle.
At this point in time by means of a curette and a rongeur, the head of the
clavicle was partially debrided. The cavity was irrigated thoroughly with
irrigator solution. At the completion of the procedure, a wound VAC sponge
was tailored and placed in the wound. The wound VAC was placed to 125 mmHg
continuous pressure. The patient is to be monitored in PACU.