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Using the current year ICD-10-CM manual or website:...

Using the current year ICD-10-CM manual or website: https://icd10cmtool.cdc.govLinks to an external site., provide the diagnosis code for the patient case.
 PREOPERATIVE DIAGNOSIS: Pyogenic granuloma, sinus tract, buttock.

POSTOPERATIVE DIAGNOSIS: Multiple sinus tracts, one extending inferiorly about 7 x 3 cm in diameter, one extending to the right approximately 4 x 3 cm, and one extending to the left for about 3 cm.

SURGICAL FINDINGS: As above, plus granulation tissue present in a capsule of multiple sinus tracts. Sinus tracts measured a total of about 15 x 8 cm in their total dimensions.

SURGICAL PROCEDURE: Partial unroofing (debridement) of sinus tracts.

SURGEON: Tony Wellbed, MD

ANESTHESIA: General endotracheal.

DESCRIPTION OF PROCEDURE: The patient was intubated and turned in the prone position. A probe was inserted in the sinus cavity, and dissection debridement was carried down into the subcutaneous tissue with 15 sq. cm. debrided. I encountered a piece of chronically infected granulation tissue coming out of a hole, in which I stuck the probe, but this continued for a distance longer than the probe and accordingly, I put my finger in this and this extended down the length of my index finger (about 7-8 cm by about 3 cm in width). I left this in- tact, because this would necessitate extensive dissection and we have no blood on this patient at this time. We then unroofed two other sinus cavities, and packed this open with 2-inch vaginal packing and applied a dressing and Kerlix plus an Elastoplast. Estimated blood loss: 25 cc. The patient seemed to tolerate the procedure well and left the operating room in good condition.

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Using the current year ICD-10-CM manual or website: https://icd10cmtool.cdc.govLinks to an external site., provide the diagnosis code for the patient case. PREOPERATIVE DIAGNOSIS: Pyogenic granuloma, sinus tract, buttock. POSTOPERATIVE DIAGNOSIS: Multiple sinus tracts, one extending inferiorly about 7 x 3 cm in diameter, one extending to the right approximately 4 x 3 cm, and one extending to the left for about 3 cm. SURGICAL FINDINGS: As above, plus granulation tissue present in a capsule of multiple sinus tracts. Sinus tracts measured a total of about 15 x 8 cm in their total dimensions. SURGICAL PROCEDURE: Partial unroofing (debridement) of sinus tracts. SURGEON: Tony Wellbed, MD ANESTHESIA: General endotracheal. DESCRIPTION OF PROCEDURE: The patient was intubated and turned in the prone position. A probe was inserted in the sinus cavity, and dissection debridement was carried down into the subcutaneous tissue with 15 sq. cm. debrided. I encountered a piece of chronically infected granulation tissue coming out of a hole, in which I stuck the probe, but this continued for a distance longer than the probe and accordingly, I put my finger in this and this extended down the length of my index finger (about 7-8 cm by about 3 cm in width). I left this in- tact, because this would necessitate extensive dissection and we have no blood on this patient at this time. We then unroofed two other sinus cavities, and packed this open with 2-inch vaginal packing and applied a dressing and Kerlix plus an Elastoplast. Estimated blood loss: 25 cc. The patient seemed to tolerate the procedure well and left the operating room in good condition.

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