Excision of draining sinus tract tibia
Please help not sure what the icd 9 codes and cpt code should be.
Diagnosis: Draining wound with associated cellulitis of the right proximal tibia laterally. Three and one-half months status post open reduction and internal fisation of a severely comminuted right tibial plateau fracture with large plates and screws both medially and laterally of the right proximal tibia.
Operative procedure: Excision of a draining sinus tract of the right proximal tibia laterally followed by thorough irrigation and primary closure of the wound.
Op. Finding revealed a small scabbed over wound over the lateral aspect of the right proximal tibia. The wound was within a previous incision site. With excision of the cound, a sunus tract was followed all the way down to an underlying plate, cultures were obtained and although the tissue was nectortic and mildly purulen, there was no gross purulent material.
A 4 cm longitudinal ellitical incision was made incorporating the area that was scabbed over where there was a sinus tract that was draining. The incision was carried all the way down through the subcutaneous tissue, fascia, and periosteum and down to the level of the underlying plate. The wound was then carefully inspected and was irrigated with copious amounts of normal saline and bacitracin solution uning the pulse lavage. Cultures were obtained fran the necrotic appearing tissue.