A 63 year-old man sustained a gunshot wound through the right maxillary sinus penetrating into the right neck. CT scan revealed
no hard evidence of arterial injury but a bullet was directly in line with the internal jugular vein. He was sent to the operating room for neck exploration to rule out vascular injury and injury to the aerodigestive tract (respiratory and digestive tracts). A sternocleidomastoid incision was performed and carried down through the platysma muscle. There was no penetration of the internal jugular vein, but a foreign body was identified resting on the internal jugular vein at approximately the level of the angle of the mandible and it was removed. The parotid gland was noted to have a blast injury near the tail. This was not surgically repaired or resected. Once all bleeding was controlled, a 10 French round drain was placed in the wound. The wound was copiously irrigated. The platysma muscle was closed and the skin was closed with subcuticular closure. What CPT® code is reported?
Answer: Tina should worry about the fever first and get a ice pack or a cool rag to get him to his normal temperature. Doing that will make him comfortable...well at least a little. The child has pyrexia so medications such as acetaminophen and ibuprofen may help ease discomfort. Since this is a child, avoid giving him aspirin because this may cause a rare, serious condition.
