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Posted By Dorine on 09-24-2020, 13:36:14 in Ob-Gyn
Hi Ob-Gyn group, our pt has a right sided labial abscess involving labia minora and was taken to OR after previous drainage 6 months ago, procedure is as follows, after straight cath and external pelvic exam revealed the abscess drainage point/opening along the medial aspect of the right labia minora, this site of spontaneous drainage was further opened with hemostats. Internal loculations were broken up with hemostats revealing both the anterior and posterior tracts noted above. This was dissected followed by blunt dissection with a gloved finger. During this dissection the posterior tract opened spontaneously along its entire length. Once both tracts have been extensively explored for loculations or additional small pockets of purulent material, abscess tracts were copiously irrigated with normal saline. Exam revealed healthy tissue along the entire base of the abscess. A small amount of epithelial tissue is incised with mayo scissors along the posterior track extension. Bleeding incision cauterized w/ Bovie, site examined and found to be hemostatic Foley cath placed to ensure urethral patency w/ post procedure swelling, instruments removed. I had decided on 56405 but wasn't sure if that captures all that was done. Would you please advise. Thank you!
Comments (2)
Posted By Dorine on 09-30-2020, 07:56:28
Thank you so much!
Posted By Melanie Witt on 09-29-2020, 17:04:00
I would agree that 56405 is your option, but given this description I would add a modifier -22 for the additional work.
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