Pediatric Coding Alert

Question: Documentation indicates the following: PREOPERATIVE DIAGNOSIS(ES)/INDICATION: Redundant foreskin POSTOPERATIVE DIAGNOSIS(ES): Circumcised penis RESIDENT PERFORMING PROCEDURE (if any): Resident PROCEDURE AND FINDINGS:An informed consent was obtained by myself or my partner. I reviewed the document with the parent(s), verified that it was signed, and gave the parent(s) the opportunity to ask further questions. A time-out procedure was completed, verifying correct patient, procedure, site, positioning, and, or special equipment if applicable. The infant was placed on a restraining board, prepped and draped in a sterile fashion. Local anesthetic was applied as follows: ANESTHETIC AGENT: EMLA GOMCO CLAMP SIZE:1.3. The adhesions between the glans and the foreskin were separated by blunt dissections. A dorsal slit was made and the Gomco circumcision clamp was applied in the usual manner. The clamp was left on for 5 minutes for hemostasis. The foreskin was then excised with a scalpel and the clamp was removed. No [...]