tdesher
Networker
I am not sure how to code for this, Dr attempted to remove what he thought was a cyst in a thumb but after he was in there and looking around there was no cyst present so he closed up and proceeded on with the rest of the surgery. He wanted to use 26116 but I don't feel that is right if he didn't actually excise anything. See note below.
I proceeded next with the right thumb.* A longitudinal incision was designed over the ulnar midlateral aspect of the thumb, centered over the IP articulation.* The incision was carried down through the subcutaneous tissues.* Soft tissue dissection was performed extensively in this area.* The ulnar digital nerve was identified and carefully protected throughout the duration of surgery.* The trifurcation point and the resultant sensory nerves were also identified and protected.* There was no evidence of soft tissue mass.* There was no evidence of cystic lesion in this particular area.* A small longitudinal incision was made over the collateral ligament.* There was no evidence for cyst embedded or buried within this particular area.* I was not able to identify a glomus tumor or a nerve sheath tumor of any sort.
Following extensive dissection and neurolysis, skin closure was performed.
I proceeded next with the right thumb.* A longitudinal incision was designed over the ulnar midlateral aspect of the thumb, centered over the IP articulation.* The incision was carried down through the subcutaneous tissues.* Soft tissue dissection was performed extensively in this area.* The ulnar digital nerve was identified and carefully protected throughout the duration of surgery.* The trifurcation point and the resultant sensory nerves were also identified and protected.* There was no evidence of soft tissue mass.* There was no evidence of cystic lesion in this particular area.* A small longitudinal incision was made over the collateral ligament.* There was no evidence for cyst embedded or buried within this particular area.* I was not able to identify a glomus tumor or a nerve sheath tumor of any sort.
Following extensive dissection and neurolysis, skin closure was performed.