I would appreciate help coding the following procedure:
1. Right-sided scalp wound revision & debridement of necrotic scalp tissue.
2. Closure of complex wound.
Patient who underwent a right-sided craniectomy for malignant cerebral edema & transient ischemic stroke with failure of the wound to heal. Because of concerns that the patient may develop a further super infection, he was taken to the operating room at this time.
Description of Procedure
After ascertaining the correct patient & induction of general anesthesia, a surgical time out was performed in the room by the members of the surgical team.
Once this was done, the area of the previous incision was reopened with a combination of a #10 blade & monopolar electrocautery.
Dissection continued through the cortical galeal adhesions.
No purulent material was found, although some necrotic skin edges were actually found. These were debrided & removed with the use of tenotomy scissors.
Further dissection & removal of the cortical galeal adhesions revealed no evidence of any abscess. Copious amounts of Bacitracin irrigating solution were used to irrigate the overlying cortex as well as scalp. Bleeding points were controlled with bipolar electrocautery. Surgicel was placed over the galea, and after this was done closure began by approximating the galea with 2-0 Vicryl & the skin with 0-Prolene in a vertical mattress fashion. Prior to closure, a Hemovac drain was placed.
The patient tolerated the procedure well.
I appreciate your help with coding this.
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