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Patient is 23 week old diagnosis with Pneumoperitoneum, likely SIP.
Procedure:
The right abdomen was prepped and draped in a sterile fashion. A small right lower quadrant incision was made. Upon entering the peritoneal cavity, air, fluid and meconium was evacuated. A 1/4-inch Penrose drain was cut to the appropriate size. One end was inserted into the abdominal cavity, directed across the abdomen. The drain was secured to the skin with 4-0 Prolene. A sterile dressing was applied.
I’m trying to determine if this is correct. The patient underwent 46040 a few days ago and due to the complexity of the abscess, they brought the patient back to the OR to perform washout and placement of a JP drain to facilitate healing.
Would I still report 11004 if he’s not actually documenting any debridement?? How do you capture revenue for bringing the patient back to the OR if he’s basically just performing wound care under anesthesia?
Op report states:
we prepped and draped the area and after our final verification we proceeded. We washed out the wound copiously with saline. We then again identified the tracking down towards the perineum close to the perianal area.
Due to the complexity of the wound and tracking, as well as difficulty with packing, I elected to leave a Penrose drain by making a small counterincision slightly into the perianal area. I made a small counterincision a couple of inches away from the already existing scrotal wound. I passed a one-inch Penrose through the deepest part of the already existing abscess cavity and once I did that we secured hemostasis. We washed out the wound further. I secured the Penrose on itself so it was looped and then placed some one-inch packing into both wounds. There were no other complications. We placed a dry gauze as well as a scrotal support and the patient tolerated the procedure well. He was taken out of lithotomy and extubated
Indications: Chronic presacral sinus secondary to anastomotic leak.
Description of Procedure: The patient was brought to the abdomen placed on the operative table in supine position. After administration of adequate anesthesia the patient was placed in lithotomy position. The patient was prepped and draped in usual sterile fashion. Timeout was performed. The patient received preoperative antibiotics in the form of Flagyl. The perianal area was injected with 30 mL of 1% lidocaine with epinephrine and 0.5% Marcaine mixed. Digital rectal examination revealed the drain was in a posterior presacral cavity. Perianal examination revealed no masses. No fistula or fissure. Digital rectal examination did not reveal any clear mass. The rectum proximal to the area of the posterior sinus was collapsed and scarred down. The drain was then removed in its entirety. The area of the posterior sinus was then probed. Passage of the new catheter which was a 12 French mushroom catheter was very difficult. Because of the angulation and granulation tissue present was difficult to advance the catheter. Approximately 1 hour was spent attempting to do this. Finally the area of the sinus was debrided bluntly and sharply. Granulation tissue was evacuated. A flexible sigmoidoscopy was performed up to the level of the collapsed rectum. There was no signs of mass. Biopsies were taken. Colonoscope was removed. The 12 French mushroom drain was then placed within the cavity. It appeared to stay in place. It was then secured to the left buttock with a 0 silk stitch. The perianal area was then cleaned dried and dressings applied. The patient was then awakened from anesthesia in stable condition.
[I]PREOPERATIVE DIAGNOSIS: Right hemisphere cerebral edema
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POSTOPERATIVE DIAGNOSIS: Same
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PROCEDURES: Right Hemicraniectomy
Placement of right frontal external ventricular drain
Use of intraoperative ultrasound
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INDICATIONS: Joyce Irene Wittenborn is a pleasant 65 y.o. with a history of a brain abscess which we evacuated 2 nights ago. She initially was neurologically stable, but declined today. A repeat CT scan was performed demonstrating a marked increase in the degree of cerebral edema surrounding her evacuated abscess. The patient was taken emergently to the OR for decompression.
PROCEDURE IN DETAIL: The patient was brought to the OR and placed under general anesthesia and then positioned supine on the operating table with his head affixed in a Mayfield headrest in reverse Trendelenburg position. The ipsilateral side of the head pre-prepped with alcohol, and then a small strip of hair clipped and a question mark style incision incorporating the inferior half of her previous linear middle fossa incision was drawn out and infiltrated with 1% lidocaine with epinephrine. The entire area was prepped with ChloraPrep and draped off in sterile fashion. A time out was performed. The patient was already receiving multiple IV abx.
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The scalp incision was opened and Raney clips used then the scalp was retracted using elastic hooks and a Layla bar. Burr holes were placed then a large hemicraniectomy performed with a craniotome. Strict epidural hemostasis was achieved then the dura opened in flap fashion. Onlay surgicel was used. Surgicel and suprafilm were placed under the exposed temporalis. Using intraoperative ultrasound, a right frontal antibiotic impregnated EVD was placed to a depth of 6.5 mm with spontaneous egress of csf under mild to moderate pressure. A 10mm flat JP drain placed subdurally and tunneled posteriorly. The scalp was closed in standard fashion using Vicryl followed by Vicryl Rapide.The wound was dressed in sterile fashion. There were no apparent complications during the case.
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Usually when drains are placed they only perform burr holes but he does burr holes along with a hemicraniectomy.
I was wondering if I should just go ahead and use the burr holes for EVD placement (61210) or would Craniectomy for drainage of intracranial abscess (61320) be more appropriate?
The patient does have a history of a brain abscess and then ended up developing a cerebral edema around it.
I just want to make sure that Im using the best code for this situation.
Thanks in advance for any help!