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  1. User id : 4743 Posted 2 years ago

    Please help with the following op note

    Postoperative diagnosis: Chronic draining sinus tract of the abdominal wall secondary to retained fascial suture.

    Procedure performed: Excision and debridement of chronic draining sinust tract with removal of fascial suture and layered wound closure.

    A 5 cm elliptical incision was made and carried through the subcutaneous tissues. The sinus tract was probed. It was noted to extend down to the fascia. There was a suture palpable at the base of the tract. The tract, granulation tissue, and scarring were excised completely using electrocautery. Dissection was carried down to the level of the fascia where an approximately 6 inch lenght Ethibond suture was found beneath the fascia. This was excised completely. The anterior portion of the fascia was opened. The remaining chronic granulation tissue was debrided. No further suture material was indentified. The wound was irrigated with wterile saline and carefully inspected to ensure adequate hemostasis.

    The wound was then infiltrated with 0.25 Marcaine solution. A sterile rubben band was placed in the previous sinus tract cavity and brought out through a separate stab wound incision. The rubber band functioning as a drain was sutured in place with 4-0 Monocryl sutures. The subcutaneous tissues were closed in layers using 3-0 PDS interrupted sutures. The skin was close using a 4-0 Monocryl running subcuticular suture.

    I have 10121 and intermediate closure 12032?

  2. SuperCoder Posted 2 years ago

    Yes you can report both of the code (10121 and 12032) for the above case.

  3. User id : 4743 Posted 2 years ago

    Thank you

About this Question

  • Posted by 4743, 2 years ago. There are 3 posts. The latest reply is from 4743.