Hi, can someone help me with the following surgery and DX? Thanks in advance
The opened incision on the left breast was opened for
a few millimeters medially, so the area could be probed. There was a
tunnel that extended inferiorly for approximately 3 to 4 cm. The skin
overlying this area was extremely thin and was preventing adequate
drainage of this underlying tunneled cavity. The skin over the
tunneled cavity was excised using a 15 blade. Blood supply was
excellent. The wound was irrigated. There were actually signs of
granulation tissue at the base of the wound. There was no significant
tissue that was nonviable than the possibility of the skin that was
excised. The wound was packed open using saline moistened Kerlix
gauze. Sterile dressings and an ABD pad were applied. At the
completion of the procedure, all sponge, needle and instrument counts
were correct. Estimated blood loss was 20 mL. The patient tolerated
the procedure well and was transported to the PACU in stable
The CPT I believe I should code 11042 and the DX I have is 879.0 OR 879.1 ( not sure if I should use the complicated one, does the doctor have to say complicated in order to use?) I was thinking complicated, based on the dx from the path. I also have 611.0 as well.
Tha path report says:
skin and underlying soft tisue showing acute and chronic inflammation with Foreign Body Giant Cell Reaction, No malignancy.
I am not sure what to code for Foreign Body Giant cell reation. If I go under Reaction inflammatory, it brings me back to 611.0. Reaction FB brings me to 728.82. should I leave it as 611.0? I looked up the definition to this and found:Reaction in skin to the presence of foreign body includes granulomatous inflammation with giant cells.
Thank you so much in advance!
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