I need to see how some of you would code this, the doctor is suggesting 28002 but has asked me to see what I think. The patient had a complication with some Vicryl sutures and now has a nonhealing wound. Here is the main part of the report:
Attention was then directed to the previous incision site along the plantar medial aspect of the left heel and arch region. Increased amounts of fibrotic tissue with mild maceration was noted. The fibrotic tissue was excised via sharp dissection down through the skin and subcutaneous tissues to the deeper structures. Several Vicryl sutures were noted in complete knots showing no sign of degrading or dissolving. They were removed in toto. Further fibrotic tissue was noted and debrided and sent for pathological evaluation in the form of gross and micro and culture and sensitivity to determine if any bacteria is present. At this point in time, three liters of normal sterile saline impregnated with 50,000 units of bacitracin was irrigated through the wound in pulsatile lavage type fashion. Deep closure was performed with 3-0 chromic suture times two followed by skin closure with 3-0 nylon and 4-0 nylon suture in simple interrupted fashion.
Any help will be greatly appreciated.
Elaine
Attention was then directed to the previous incision site along the plantar medial aspect of the left heel and arch region. Increased amounts of fibrotic tissue with mild maceration was noted. The fibrotic tissue was excised via sharp dissection down through the skin and subcutaneous tissues to the deeper structures. Several Vicryl sutures were noted in complete knots showing no sign of degrading or dissolving. They were removed in toto. Further fibrotic tissue was noted and debrided and sent for pathological evaluation in the form of gross and micro and culture and sensitivity to determine if any bacteria is present. At this point in time, three liters of normal sterile saline impregnated with 50,000 units of bacitracin was irrigated through the wound in pulsatile lavage type fashion. Deep closure was performed with 3-0 chromic suture times two followed by skin closure with 3-0 nylon and 4-0 nylon suture in simple interrupted fashion.
Any help will be greatly appreciated.
Elaine