Hi list I am needing some guidance on how others would code.. 24105 or 24066? I have attached path findings as well.
TIA
MB,CCS,CPC
BRIEF CLINICAL HISTORY
Left elbow mass. 20 year history of rheumatoid arthritis.
GROSS:
Specimen labeled mass, left elbow is a 2.2 x 1.3 x 1.1 cm firm irregular
white to yellow nodule with one glistening smooth white surface with the
remaining surfaces having irregular nodularity. Entirely submitted in
1A-1B.
AB/sc/FO
MICROSCOPIC DIAGNOSIS:
Soft tissue, mass of left elbow, excision: Necrobiotic Granuloma.
See comment
COMMENT: The differential diagnosis includes a rheumatoid nodule, deep
granuloma annulare and an infectious process. A rheumatoid nodule is
favored. Clinical correlation is suggested.
PREOPERATIVE DIAGNOSIS(ES):
left olecranon bursitis with rheumatoid nodule
POSTOPERATIVE DIAGNOSIS(ES):
Same as above
OPERATIVE FINDINGS:
Consistent with diagnosis.
PROCEDURE(S)/OPERATION(S) PERFORMED:
Left olecranon bursectomy with excision of rheumatoid nodule (soft tissue mass excision
ANESTHESIA:
MAC - Local
FLUIDS:
300 cc
ESTIMATED BLOOD LOSS:
<20 cc
TOURNIQUET TIME:
12 minutes
SPECIMENS:
To pathology
SUMMARY:
After obtaining informed consent, the patient was brought to the operating room, placed in a supine position on the operating room table. Once adequate anesthesia was obtained, a tourniquet was applied to the patient's left upper arm. The left upper extremity was prepped and draped in the usual sterile manner. The area of planned incision including her scar was infiltrated with marcaine with epinephrine (8cc). Following elevation of the extremity, the tourniquet was inflated to 250 mmHg.
An incision was made dorsally over the mass at the olecranon. Careful dissection was performed and all normal structures were surgically released from the mass. The mass appeared consistent with a rheumatoid nodule, but there was associated olecranon bursal tissue. The involved bursa was excised from the triceps insertion and off of the scar skin from her previous surgeries. It was submitted to pathology. All gross eveidence of the mass was removed. The wound was irrigated. The tourniquet was deflated and hemostasis was achieved with bipolar. The wound was irrigated again. The incision was closed. A sterile dressing was applied.
Anesthetic was removed. The patient was taken to the recovery room in satisfactory condition. The patient tolerated the procedure well and all sponge and needle counts were correct x2.
TIA
MB,CCS,CPC
BRIEF CLINICAL HISTORY
Left elbow mass. 20 year history of rheumatoid arthritis.
GROSS:
Specimen labeled mass, left elbow is a 2.2 x 1.3 x 1.1 cm firm irregular
white to yellow nodule with one glistening smooth white surface with the
remaining surfaces having irregular nodularity. Entirely submitted in
1A-1B.
AB/sc/FO
MICROSCOPIC DIAGNOSIS:
Soft tissue, mass of left elbow, excision: Necrobiotic Granuloma.
See comment
COMMENT: The differential diagnosis includes a rheumatoid nodule, deep
granuloma annulare and an infectious process. A rheumatoid nodule is
favored. Clinical correlation is suggested.
PREOPERATIVE DIAGNOSIS(ES):
left olecranon bursitis with rheumatoid nodule
POSTOPERATIVE DIAGNOSIS(ES):
Same as above
OPERATIVE FINDINGS:
Consistent with diagnosis.
PROCEDURE(S)/OPERATION(S) PERFORMED:
Left olecranon bursectomy with excision of rheumatoid nodule (soft tissue mass excision
ANESTHESIA:
MAC - Local
FLUIDS:
300 cc
ESTIMATED BLOOD LOSS:
<20 cc
TOURNIQUET TIME:
12 minutes
SPECIMENS:
To pathology
SUMMARY:
After obtaining informed consent, the patient was brought to the operating room, placed in a supine position on the operating room table. Once adequate anesthesia was obtained, a tourniquet was applied to the patient's left upper arm. The left upper extremity was prepped and draped in the usual sterile manner. The area of planned incision including her scar was infiltrated with marcaine with epinephrine (8cc). Following elevation of the extremity, the tourniquet was inflated to 250 mmHg.
An incision was made dorsally over the mass at the olecranon. Careful dissection was performed and all normal structures were surgically released from the mass. The mass appeared consistent with a rheumatoid nodule, but there was associated olecranon bursal tissue. The involved bursa was excised from the triceps insertion and off of the scar skin from her previous surgeries. It was submitted to pathology. All gross eveidence of the mass was removed. The wound was irrigated. The tourniquet was deflated and hemostasis was achieved with bipolar. The wound was irrigated again. The incision was closed. A sterile dressing was applied.
Anesthetic was removed. The patient was taken to the recovery room in satisfactory condition. The patient tolerated the procedure well and all sponge and needle counts were correct x2.