Forum - Questions & Answers

Oct 24th, 2013 - wendycpc

Abdominal Wall Wound Exploration

I'm stymed on what CPT® code to use?Patient has in the past had multiple ab surgeries. Patient has no evidence of EC fistula.

The patient was taken back to the operating room where he was placed supine. SCDs were placed to his legs. A 5000-unit heparin was administered subcutaneously for DVT prophylaxis. 2-g Ancef was administered intravenously. His abdomen was prepped and draped in usual sterile fashion. A time-out was performed. The sinus located in the midline epigastric area. A 3-cm long incision was made from the sinus and ran caudally using a scalpel. Then, the incision was brought down to fascia using Bovie. The inferior wall of the sinus was completely opened. An old prolene suture with knots was found superficial to the fascia and found loose. This was cut and removed. The sinus track was probed and found running inferiorly behind the anterior sheath of rectus abdominis. The fascia was cut open using Bovie until the track was full opened. Rectus abdominis muscle was exposed. There was no purulent discharge. No other tracks were found. There was no communication into the peritoneal cavity. A this point, irrigation was performed. Adequate hemostasis was achieved with Bovie. Then, the wound was packed with a moisture 4 x 4 gauze covered with dry gauzes.



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