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Posted 2 days ago #
Could you tell me how to code the following?
Indications for procedure: A 31 YO para 1 white female who had a cesarean section for breech presentation on 1/25/2012. The night of her surgery she developed bleeding and oozing forn the inceicion which disrupted its integrity. On postop day one the incision had broken apart at its right margin and there was bleeding forn the area. It was not considered salvageable for secondary healing. The original closure above the fascial level was with Dermabond on the skin with embedded Steri-Stirps. The patient was recommended for exploration, debridement and primary reclosure of the incision site.
Findings: Hematoma throughout the subcutaneous tissue, with skin separation and breakdown. No eveidence of infection. No evidence of fascial dehiscence.
Description of procedure:
The patient was taken to the operating room. Ancef 1 gram was given intravenously. She was sedated as above. The remaining Steri-Strips and Dermabond were removed and the incision allowed to open. The surrounding skin was generously prepped with Betadine. She was draped in the customary fashion.
Blood clot and debris was removed. The subcutaneous space was debrided with copious amounts of iirigating fluid and laparotomy tapes. Fresh bleeding edges were developed and an additional half liter of fluid was used to irrigate in this area. A few small bleeding points were made hemostatic. Satisfied wiht the appearance of the subcutaneous fat at this time, interrupted 2-0 plain gut sutures were used across the space to close the subcutaneous space. The skin was then closed with subcuticular 4-0 Monocryl. Steri-Strips and sterile dressings were applied. A pressuer dressing and Tegaderm were used. then 10 ml of 0.25% Marcaine was used as a posoperative anesthetic. The bladder was then emptied as well prior to departing the OP. The patient was transferred to the PACU in stable condition.
