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Need help !!

  1. Default Need help !!
    Medical Coding Books
    Hi All,

    Can anybody suggest me a suitable cpt and ICD codes for the following surgery.

    HISTORY: Mr. X is a 46-year-old Hispanic gentleman who has had a prior severe facial infection resulting in an anterofacial fistula. He has a small persistent area in need of closure

    INDICATION: Right anterofacial fistula.

    PREOPERATIVE DIAGNOSIS: Right anterofacial fistula.

    POSTOPERATIVE DIAGNOSIS; Right anterofacial fistula.

    PROCEDURE: Local closure of right anterofacial fistula.

    DESCRIPTION OF OPERATION: Mr. X was taken to the procedure room and placed in the supine position. The right side of his face was prepped and draped in the usual sterile fashion. Subsequently, the wound was inspected and infiltrated with 1% lidocaine with 1:100,000 epinephrine. The epithelial margins of the fistula were excised. Subsequently undermining of the wound was performed circumferentially. Next, the wound was closed in 2 layers with 4-0 chrornic suture. Excellent reapproxirnation of the margins was achieved. He tolerated the procedure well. He will be seen in followup in approximately a week and a half.


    Last edited by prem_ponnuru; 06-18-2009 at 01:14 AM.

  2. #2
    What did you come up with?

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