Hi everyone. Hoping I can get some help with this OP note. The A-cell implant always gets me. I believe the 15777 should be used, but I can't figure out what main code to use. Any takers?
Indication for Surgery: Poorly healing abdominal wound
Preoperative Diagnosis Same
Postoperative Diagnosis Same
Operation Evaluation and placement of a cell abdominal wall reconstruction technique.
Anesthesia Gen. endotracheal anesthesia
Estimated Blood Loss Minimal
Urine Output Not applicable
Findings 8 8 x 10 cm abdominal wall defect with biological mesh seen underneath small amount of angiogenesis granulation tissue seen
Specimen(s) None
Complications None
Technique This very delightful woman well-known to the surgical service with multiple operations including abdominal reconstruction with biological mesh secondary to intra-abdominal catastrophe with the breakdown of her anastomosis due to her malnutrition as well as our Roux-en-Y gastric bypass surgery. After full exposure risk and benefits including but not limited to bleeding infection and possibility of multiple operation patient was very eager to proceed. Surgical timeout was done. Perioperative antibiotics were administered. Wound VAC was removed from her abdominal wall very clean healthy tissue on her biological mesh underneath the defect was approximately 8 x 10 cm in size. Using the A cell technique the pocket was then placed on the abdominal wall above the biological mesh and then the mesh was then placed on top of that with Xeroform on top of that and covered with an ABD dressing. Patient's heart procedure well EBL was less than 5 mL sponge count correct ?2. Betadine was used on the wound
Surgical Sweep Complete (Yes/No/Not Applicable) Yes
Disposition PACU
Follow up plan Will need to be admitted to the hospital for continue observation of the abdominal wound as well as nutritional support with TPN.
Signature Line (Verified)
Thanks,
Kelly, CPC-A
Indication for Surgery: Poorly healing abdominal wound
Preoperative Diagnosis Same
Postoperative Diagnosis Same
Operation Evaluation and placement of a cell abdominal wall reconstruction technique.
Anesthesia Gen. endotracheal anesthesia
Estimated Blood Loss Minimal
Urine Output Not applicable
Findings 8 8 x 10 cm abdominal wall defect with biological mesh seen underneath small amount of angiogenesis granulation tissue seen
Specimen(s) None
Complications None
Technique This very delightful woman well-known to the surgical service with multiple operations including abdominal reconstruction with biological mesh secondary to intra-abdominal catastrophe with the breakdown of her anastomosis due to her malnutrition as well as our Roux-en-Y gastric bypass surgery. After full exposure risk and benefits including but not limited to bleeding infection and possibility of multiple operation patient was very eager to proceed. Surgical timeout was done. Perioperative antibiotics were administered. Wound VAC was removed from her abdominal wall very clean healthy tissue on her biological mesh underneath the defect was approximately 8 x 10 cm in size. Using the A cell technique the pocket was then placed on the abdominal wall above the biological mesh and then the mesh was then placed on top of that with Xeroform on top of that and covered with an ABD dressing. Patient's heart procedure well EBL was less than 5 mL sponge count correct ?2. Betadine was used on the wound
Surgical Sweep Complete (Yes/No/Not Applicable) Yes
Disposition PACU
Follow up plan Will need to be admitted to the hospital for continue observation of the abdominal wound as well as nutritional support with TPN.
Signature Line (Verified)
Thanks,
Kelly, CPC-A
Help with A-cell & wound closure
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