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Exploration surgical wound 7 days postop?

  1. #1
    Post Exploration surgical wound 7 days postop?
    Medical Coding Books
    Surgeon performed Enterotomy, small bowel for decompression on 9/23. Cultures came back postiive for clostridium perfringens and moderate gram negative bacilli, and patient small wound dehiscence with small amount of fibrinous-purulent drainage on the 30th. Surgeon reopened the wound at bedside to explore and probe for further infection and drain purulence with packing and bulky dresseing being applied following exploration.

    Is the expolration separately billable and if so what is the CPT?

  2. #2
    Milwaukee WI
    Default Please post the scrubbed note
    For an accurate response to surgical coding questions, please post the scrubbed operative / procedure note.

    From your brief description this may have been an I&D, complicated. But I can't really tell without seeing the actual procedure note.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Exploration Wound Procedure note:

    ...Patient's incision gently probed through the opening where he had sme purulence, currently there is no tract entering into the abdomen. Several staples above and below this were removed and incision opened, patient had pururlent material, this did extend superiorly and the wound was opened 6/8 cm. All purulence was drained, surrounding tissue reveals good granulation. Facial closure was viewed and intact and there is no intraabdominal extension, wound otherwise healed from inferior aspect up to above his umbillicus. All staples were removed, the lower wound was left intact but no strips were placed, the upper wound was opened adn the area of purulence drained. No evidence of necrosis or gas gangrene. This was sterily packed with absorbent dressing followed by large dressing.

    Following is part of the Original Surgery Note stating the original incision information (Exp Lap, extensive adhesiolysis, decompression of small bowel):

    Previous insicion (prev ruptured appendectomy/exp lap) had been centered around his umbilicus and was 8-10 cm, this was reopended and extended superiorly to this incision. Dissection was carried down to the skin and subcutaneous tissues to the fascia. Abdomen was entered above the patient's previous incision, the fascia was opened.

    Any help would be appreciated!

  4. #4
    Any suggestions on the attached note for the wound exploration?

  5. #5
    Milwaukee WI
    Default 11042?
    I'm thinking that 11042 most closely describes what was done.

    Anyone else have an opinion?

    F Tessa Bartels, CPC, CEMC

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