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Excision of sinus tract and hyperkeratosis

  1. #1
    Default Excision of sinus tract and hyperkeratosis
    Medical Coding Books
    Post Op Dx: Left chin lesion, possible abscess tract

    The left face was prepped and draped in sterile fashion. A #15 blade was used to make an incision in an elliptical fashion on the left chin lesion after 1% lidocaine with epinephrine was injected into the site for topical vasoconstriction. This was dissected free from the adjacent tissue and it could be seen that there was a tract indeed what appeared to be extending down deep to the mandible. This was followed all the way to the mandible an ultimately was transected and tied off with a 4-0 silk suture. Minimal bleeding was encountered, which was cauterized with bipolar cautery. The wound was irrigated. A 4-0 Vicryl was used to close the deep portions of the incision and a 5-0 Nylon was used to close the superficial layer in interrupted fashion.

    Path: Final Diagnosis Skin, Chin, Excision: Sinus tract with abundant hyperkeratosis

    The patient had an abscess on his left chin, and his PCP lanced it and everything recurred and seemed to worsen.
    I was considering 13160, or would the sinus tract be incidental to the excision, since the procedure was for the excision of the chin lesion? Any help is greatly appreciated!!!
    Last edited by bethh05; 04-11-2011 at 02:45 PM.

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