ksrkelly7
Networker
Hi there. I need some help with this OP report. Doc wants to bill 38500 for a deep lymph node excision of cheek. Is there another option? I read that all facial lymph node excisions are superficial, but this one goes down to muscle. I did question him about using CPT 21013, excision soft tissue, subfascial, but the path came back as a really high level 2 lymph node with granulomatous lymphadentitis. Any thoughts?
Preoperative Diagnosis
Localized enlarged lymph nodes
Right cheek mass
Postoperative Diagnosis
Same.
Operation
Excision right cheek mass.
Anesthesia
Gen.
Estimated Blood Loss
Minimal.
Findings
~1.5 cm right deep cheek mass. Irregular, whitish, firm. Partially cystic; although mostly solid. Consistent w/ lymph node vs tumor. Sent for fresh lymphoma workup and cultures for GS/C&S.
Specimen(s)
Right cheek.
Complications
None.
Technique
The patient was taken back to the main operating room. General anesthesia was induced without difficulty. Patient was intubated. Following this a shoulder roll was applied. We marked the planned incision and injected it with _5 mL 1% lidocaine with 1:100,000 epinephrine. The patient was prepped and draped in the usual fashion. Several minutes were allowed to lapse. Thereafter a _2.5 cm incision was made with a bovie in the right buccal mucosa inferiorly through mucosa, subcutaneous tissue, and muscle. We dissected over and around the mass with the Metzenbaum scissors & using retractors for exposure. The boundaries were superiorly- the buccal muscle, medially- the mandible, posteriorly- the parotid gland. It appeared to be consistent with a lymph node vs tumor; whitish with a firm irregular capsule, but also partially cystic. Hemostasis was achieved with the electrocautery. Wound bed irrigated thoroughly w/ saline solution. We placed several pieces of postage stamp size Surgicel into the wound. We _did not place a #7 flat JP drain. The wound was closed in layered fashion with 4-0 chromic suture, and the mucosa was closed with a running locking 4-0 chromic. Antibiotic ointment was applied to the lips. At the conclusion the patient awoke from anesthesia in good condition. Disposition _she is currently stable in the recovery room.
Thanks for any help,
Kelly - CPC
Preoperative Diagnosis
Localized enlarged lymph nodes
Right cheek mass
Postoperative Diagnosis
Same.
Operation
Excision right cheek mass.
Anesthesia
Gen.
Estimated Blood Loss
Minimal.
Findings
~1.5 cm right deep cheek mass. Irregular, whitish, firm. Partially cystic; although mostly solid. Consistent w/ lymph node vs tumor. Sent for fresh lymphoma workup and cultures for GS/C&S.
Specimen(s)
Right cheek.
Complications
None.
Technique
The patient was taken back to the main operating room. General anesthesia was induced without difficulty. Patient was intubated. Following this a shoulder roll was applied. We marked the planned incision and injected it with _5 mL 1% lidocaine with 1:100,000 epinephrine. The patient was prepped and draped in the usual fashion. Several minutes were allowed to lapse. Thereafter a _2.5 cm incision was made with a bovie in the right buccal mucosa inferiorly through mucosa, subcutaneous tissue, and muscle. We dissected over and around the mass with the Metzenbaum scissors & using retractors for exposure. The boundaries were superiorly- the buccal muscle, medially- the mandible, posteriorly- the parotid gland. It appeared to be consistent with a lymph node vs tumor; whitish with a firm irregular capsule, but also partially cystic. Hemostasis was achieved with the electrocautery. Wound bed irrigated thoroughly w/ saline solution. We placed several pieces of postage stamp size Surgicel into the wound. We _did not place a #7 flat JP drain. The wound was closed in layered fashion with 4-0 chromic suture, and the mucosa was closed with a running locking 4-0 chromic. Antibiotic ointment was applied to the lips. At the conclusion the patient awoke from anesthesia in good condition. Disposition _she is currently stable in the recovery room.
Thanks for any help,
Kelly - CPC