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Wide debridement and incision and drainage of left groin abscess

  1. Default Wide debridement and incision and drainage of left groin abscess
    Medical Coding Books
    I'm confused on which procedure code to use, do I use 10060 or 11040? Any help would be greatly appreciated
    The procedure, risks, benefits and alternatives were discussed with the patient prior to
    surgery. Patient understood and consented to operation.
    CHIEF COMPLAINT: Left Groin pain with large abscess and cellulitis.
    PROCEDURE: Wide debridement and incision and drainage of left groin abscess.
    DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the usual fashion in the supine position under general anesthesia. LMA was used. Unasyn 3 IV piggy back was given preoperatively. The left groin was inspected. There was a large amount of gas effusion from the area when it was opened probably some gas gangrene forming organism. Intraoperative cultures aerobic and anaerobic were taken and sent to microbiology for evaluation. The area was debrided of a necrotic infected tissue. All of the pus was removed. Irrigation was performed with a liter of saline until clear and clean. Hemostasis was acquired and good. The area was inspected. There was no hiding loculations. The abscess was completely drained and debrided. At this point, the wound was packed gently with sterile saline moistened kerlix gauze and ABD pads were placed on top of this. Dressings were applied. 30cc of 0.25% Marcaine with epinephrine was infused into the area for postoperative relief. At the end of the operation, sponge and needle count were correct x2. Estimated blood loss was 100 cc. Patient tolerated the procedure and anesthesia well and was transferred to recovery in stable condition.

  2. #2
    Milwaukee WI
    Default Neither
    11040 is deleted from the 2011 CPT book
    10060 is for a SIMPLE I&D.

    I would code 10061 I&D of Abscess, complicated.

    Hope that helps

    F Tessa Bartels, CPC, CEMC

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