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Excision of axillary dog ear with involved sinus.

  1. Default Excision of axillary dog ear with involved sinus.
    Medical Coding Books
    I'm completely confusing myself with this one. I'm not sure exactly what to use for both the dx code and the procedure. Any help would be so greatly appreciated.

    Draining sinus left posterior axillary line following previous mastectomy about a year ago.

    Draining sinus left posterior axillary line following previous mastectomy about a year ago.

    Excision of axillary dog ear with involved sinus.

    The patient was brought to the operating room. After attainment of sufficient general anesthesia, she was pretreated with antibiotics and prepped and draped in the usual sterile fashion, but before we prepped her, we made an initial prep and closed the sinus with some interrupted sutures of 4-0 silk, which totally closed the sinus. We then used Dermabond and, again, we had prepped the area, we then dermabonded, glued, put surgical adhesive over that area to isolate it. Then, we prepped and draped, and then covered the entire area with a Vi-Drape, and only then did we make an elliptical incision removing the dog ear, and this was probably about close to, I would say probably about 12 cm long and about 6 cm wide area, just sort of an ellipse and took out this dog ear in its entirety. We never exposed the wound at the time of the case. Once we had done our excision, we just made a sharp incision and then we used Bovie. Then, swabbed the whole area with Betadine. Although, again, there was no exposure of this draining sinus to this wound. We then swabbed it with Betadine and closed with deep sutures of 3-0 Vicryl and then closed the skin with staples. The patient tolerated the procedure quite well.

  2. Default Thoughts?
    Just wondering on other thoughts on this one...

    CPT: 15839
    Dx: 998.6, 701.9

    Anyone agree/disagree?


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