Still fairly new to surgeries, any suggestions on what to code for this case. I had thought of 20103, but not sure......
Mb,CCS,CPC
Preoperative Diagnosis: non healing surgical wound, right lower extremity
Postoperative Diagnosis: same
Procedure Performed: Wound exploration, removal of foreign body
placement of 100gm of matristem micromatrix
Anesthesia:Anesthesia of Choice
Anesthesiologist:Anesthesiologist:
Antibiotics:ancef 2 gm IV
Complications: none
IV Fluids: 500ml
Estimated Blood Loss: Minimal
Specimens: None
Procedure Findings: Deep tycron suture found
Condition of Patient:
The patient was transferred in stable condition.
Summary:
The patient was transferred to the OR and placed into a supine position. General LMA anesthesia was induced. The patient was prepped and draped. A formal timeout procedure was then performed. Once all members of the operative team were in agreement the procedure commenced.
A lenticular incision was made surrounding the sinus track opening. A cotton tipped applicator was used to delineate the track. Electrocautery was used to dissect the track. At the base of the sinus track a single tycron suture was encountered. The suture was clipped and removed. The wound was completely explored and no additional abnormalities encountered. Ronguers were used to completely debride the wound 2x2cm2 of all devitalized tissue. The wound was irrigated and hemostasis ensured. 100gm of powdered xerograft was then carefully applied to the wound. The wound was closed in layers beginning with deep dermal interrupted 2-0 vicryl and skin closure with interrupted 2-0 nylon. Dry guaze was applied for dressing.
Patient was allowed to awaken from anesthesia and the LMA device was removed. He was then transferred to the PACU in stable condition. The patient tolerated the procedure well, no complications. Count were correct x2.
Mb,CCS,CPC
Preoperative Diagnosis: non healing surgical wound, right lower extremity
Postoperative Diagnosis: same
Procedure Performed: Wound exploration, removal of foreign body
placement of 100gm of matristem micromatrix
Anesthesia:Anesthesia of Choice
Anesthesiologist:Anesthesiologist:
Antibiotics:ancef 2 gm IV
Complications: none
IV Fluids: 500ml
Estimated Blood Loss: Minimal
Specimens: None
Procedure Findings: Deep tycron suture found
Condition of Patient:
The patient was transferred in stable condition.
Summary:
The patient was transferred to the OR and placed into a supine position. General LMA anesthesia was induced. The patient was prepped and draped. A formal timeout procedure was then performed. Once all members of the operative team were in agreement the procedure commenced.
A lenticular incision was made surrounding the sinus track opening. A cotton tipped applicator was used to delineate the track. Electrocautery was used to dissect the track. At the base of the sinus track a single tycron suture was encountered. The suture was clipped and removed. The wound was completely explored and no additional abnormalities encountered. Ronguers were used to completely debride the wound 2x2cm2 of all devitalized tissue. The wound was irrigated and hemostasis ensured. 100gm of powdered xerograft was then carefully applied to the wound. The wound was closed in layers beginning with deep dermal interrupted 2-0 vicryl and skin closure with interrupted 2-0 nylon. Dry guaze was applied for dressing.
Patient was allowed to awaken from anesthesia and the LMA device was removed. He was then transferred to the PACU in stable condition. The patient tolerated the procedure well, no complications. Count were correct x2.
