Op Report
Procedure: Wide local excision of genital warts
Findings: Multiple genital warts, some were very thickened with wide bases, not amenable to laser or treatment with TCA or cryotherapy. Very large 2X2 thickened warts in the perineum, one on the left and one on the right. Other, smaller warts around the perineum. Ulcerative lesion on the right labia
Anesthesia: General
** Each wart was grasped with toothed forcep and a wide local excision performed using scalpel. Multiple warts removed, in total about 8. Sent for pathology. 3-4 were in the right labia area. Some bleeding noted after excision; controlled with pressure and use of silver nitrate sticks and interrupted sutures using 3-0 monocryl. The 2 larger warts had wide bases and therefore the dead space was closed with interrupted sutures of 3-0 vicryl to minimize tension on skin. Skin edges were reapproximated in a subcuticular fashion using 3-0 vicryl. We did not use Bovie.
Path Report: 7 specimen: 6 returned as "Benign condyloma with HPV associated changes", one as "Ulcer biopsy, nonspecific ulceration"
My Question: In order to code this with the Excision codes, I would need to query the provider for the exact number and measurements of the lesions and the excised margins, correct? The Op Report makes it sound like the provider did not take this data down.
Procedure: Wide local excision of genital warts
Findings: Multiple genital warts, some were very thickened with wide bases, not amenable to laser or treatment with TCA or cryotherapy. Very large 2X2 thickened warts in the perineum, one on the left and one on the right. Other, smaller warts around the perineum. Ulcerative lesion on the right labia
Anesthesia: General
** Each wart was grasped with toothed forcep and a wide local excision performed using scalpel. Multiple warts removed, in total about 8. Sent for pathology. 3-4 were in the right labia area. Some bleeding noted after excision; controlled with pressure and use of silver nitrate sticks and interrupted sutures using 3-0 monocryl. The 2 larger warts had wide bases and therefore the dead space was closed with interrupted sutures of 3-0 vicryl to minimize tension on skin. Skin edges were reapproximated in a subcuticular fashion using 3-0 vicryl. We did not use Bovie.
Path Report: 7 specimen: 6 returned as "Benign condyloma with HPV associated changes", one as "Ulcer biopsy, nonspecific ulceration"
My Question: In order to code this with the Excision codes, I would need to query the provider for the exact number and measurements of the lesions and the excised margins, correct? The Op Report makes it sound like the provider did not take this data down.