Cristina Posted Tue 20th of October, 2015 17:16:28 PM
Please help me code this surgery. Patient had a excision pilonidal cyst (11772) on 9/17/15. Help me with cpt codes and icd10 diagnosis codes.
Date of procedure: 10/1/15
INDICATIONS OF PROCEDURE:
The patient is a 21-year-old female with history of Down's syndrome and
congenital heart disease, who has had a pilonidal sinus tract and disease for
many years. She subsequently had this area excised; due to her emotional
immaturity and Down's, the decision was made to do a primary closure not do a
wound VAC. The patient has done well; she did well the first week. This is her
second week postop evaluation and it looks like her inferior aspect of her wound
has dehisced. There is some exudative material present. There is no drainage
noted. There is a slight foul odor. The decision then made to have this
debrided under conscious sedation with anesthesia. Mom agrees to the procedure.
TECHNICAL ASPECT OF PROCEDURE:
After adequate IV sedation per anesthesia, the dressing was removed and the
inferior aspect of her wound had dehisced. She had some exudative built up,
which was removed with hemostats. She also had some sutures that needed to be
taken off with scissors in order to debride the superficial layer of the fat and
tissue that appeared to have broken down and died. This was all debrided.
Again, the wound was very clean after this tissue was debrided. There was
healthy tissue remaining. It appeared to be pink. There were some areas of the
fat were not as pink, but this is expected, but tissue did remain viable. The
site was cleaned with saline and, subsequently, wound was measured; it measured
6 cm in length, 3 cm in width, and 2.5 cm in diameter. Wound was subsequently
packed with Betadine gauze.
The child will be evaluated by PT, wound care tomorrow and, if this does not go
well, may need a PICC line and continuous IV sedation to have wound care done.
Mom was present during the procedure and verbalized understanding.
SuperCoder Answered Wed 21st of October, 2015 05:18:04 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 firstname.lastname@example.org for more information.