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Post op I&D VAGINAL CUFF

  1. Default Post op I&D VAGINAL CUFF
    Medical Coding Books
    My Doc did an I&D of a vaginal cuff abscess. The abscess was a post op complication of a TLH done last month. The op note list the DX as post op pelvic abscess. However this is what the op note saids:
    Examination under anesthesia revealed induration at the vaginal cuff and fullness. The weighted speculum was placed into the Vagina and with the aid of a sims retractor, the anterior vaginal cuff was grasped with Allis clamp; posterior lip likewise grasped, and moderate traction resulted in division of the the cuff with return of purulent liquid of approximately 25-30 ml. This was cultured for both aerobic and anaerobic bacteria and then explored using the sucker tip with return of further liquid. When no further liquid returned and it was obvious that further loculations could be broken up, the Allis clamps were removed. Minimal bleeding being noted, ther procedure was terminated.

    How should I code this?

    Thanks!

  2. Default
    CPT code 57010

  3. Default
    ICD -9 - 614.4 , 998.59 other post op. infection abscess (I would place post op. pelvic infection/abscess under this category ; and a personal history V code: V15.29.
    When you now the organism we could use it as additional code to 998.59.
    Hope this works.

  4. Default
    Can I use that code if technicly there was no incision made?

  5. Default
    ICD -9 - 614.4 , 998.59 other post op. infection abscess (I would place post op. pelvic infection/abscess under this category ; and a personal history V code: V15.29.
    When you now the organism we could use it as additional code to 998.59.
    Hope this works.

  6. Default
    You can use it by all means. Often the abscess ruptures with placement of an instrument /hand / or of its own before we reach it. That counts to same as the I& D or just a drainage. there is not much of cleavage between these two especially when it comes to suppurative flectuant abscesses which are already at the verge of opening up.
    Moreover the decription of the CPT code goes as"drainage", colpotomy.( here the colpotomy / incision was the intension, but it happened of its own, though. This is my analytical explanation.

    I am convinced .

  7. Default
    Thanks !

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