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Excision of AV Graft

Kelly Posted Sat 29th of October, 2016 09:24:40 AM
How would the following report be coded: PREOPERATIVE DIAGNOSIS: Infected left axillary artery femoral vein graft. POSTOPERATIVE DIAGNOSIS: Infected left axillary artery femoral vein graft. PROCEDURE: Wound exploration, debridement of skin, subcu and fascia. Excision of AV graft, placement of wound VAC x2. ANESTHESIA: General. PROCEDURE: The patient was placed in the supine position. His left neck, chest, abdomen and groin were prepped and draped following the induction of general anesthesia. A wound in the left lower quadrant of the abdomen was debrided. The graft was clearly exposed. There was pus along the track of the graft as well as erythema, extending over the involved portion of the graft. The erythema extended from the groin to the patient's left axilla. The second incision was made over a well-healed left chest counter incision and there was pus tracking along the graft at this level. The pus appeared to extend several centimeters more proximal. The graft was divided proximally and distally and removed. The graft was removed in its entirety from the left chest wall incision down to the femoral vein. No bleeding was encountered from the femoral vein. All devitalized and infected tissues were debrided with sharp dissection as well as with cautery. The groin wound was saucerized mildly. The groin wound and graft track were irrigated with 2 liters of saline containing Keflex. The wounds were irrigated until the irrigation was quite clear. It should be noted that a third incision was made directly over the graft which was localized by ultrasound in the axilla. The graft was clamped, divided, suture ligated with a 3-0 Prolene proximally and this section of the graft was removed as well. This portio of the track was irrigated. The subcutaneous tissues at this level at the most proximal incision in the left axilla were closed with a 3-0 Vicryl suture and the skin was closed with a running 4-0 Monocryl subcuticular suture. The remaining 2 wounds were then packed with a black sponge and connected using a Y connector to a wound VAC once hemostasis was insured. Swabs of the pus as well as a portion of graft were sent for culture.
SuperCoder Answered Tue 01st of November, 2016 03:10:18 AM

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.

 

 

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