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Kathy Posted 1 month(s) ago
DX POSTOP: RIGHT ELBOW ABSCESS WITH INFECTED ADJ LYMPH NODES. PROCEDURES EXCISION OF INFECTED 12x8x3 CM SOFT TISSUE ON THE RIGHT ELBOW INVOLVING SKIN,SUBCUTANEOUS TISSUE AND FASCIA LAYERED CLOSURE OF 12 CM WOUND ON THE RIGHT ELBOW. OP REPORT: . An elliptic incision around the affected tissue was drawn by the surgeon and using a #10 scalpel blade, the incision was made. The incision was then carried through the subcutaneous tissue with the electrocautery and all the way down to the fascia. The superficial fascia appeared to be involved by the infection and therefore very carefully and using the electrocautery and the LigaSure device to counteract the adjacent blood vessels, the entire patch of infected tissue including the fascia was excised. The patch measured 12 x 8 x 3 cm. Once the excision had been completed one of the infected lymph nodes was entered and a sample for Gram stain, culture and sensitivity was sent to microbiology PATH REPORT: Final Diagnosis CORRECTED REPORT (01/12/18): 1. Right elbow abscess tissue, debridement: - Chronic cutaneous abscess with fibrous granulation tissue and focal non-caseating granuloma. - Special stains for acid-fast bacilli and PAS stains for fungus are negative. - CAT scratch immunostain is negative. 2. Right elbow lymph nodes, excision: - Multiple benign lymph nodes demonstrating reactive changes with palisading granulomas (focally necrotizing). Additional areas subcutaneous abscess formation with necrosis and extranodal palisading granulomas. - Special stains for acid-fast bacilli and PAS stains for fungus are negative. - CAT scratch immunostain is negative. I THOUGHT IT WAS 11406-RT AND 12034-XU-RT, BUT SOMEONE ELSE USED 24073-RT AND 12034-XU-RT WHICH WOULD IT BE??
SuperCoder Posted 1 month(s) ago

Hi Kathy,

AAE does not provide coding for operative reports and chart notes.

SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail customerservice@supercoder.com for more information. Thank you.

Posted by Kathy, 1 month(s). There are 2 posts. The latest reply is from SuperCoder.

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