Question Abdominal fat-pad biopsy

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2
Location
Sedalia, MO
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I am newer to coding general surgery and was wondering if someone could give me direction on the proper way to code this.. here is the op note:
Diagnosis: rule out amyloidosis
Path report dx :
Soft tissue, abdominal fat pad biopsy
-- No evidence of amyloid deposition.
-- Congo red special stain is negative.


DESCRIPTION OF PROCEDURE: The patient's abdomen was prepped and draped
in sterile fashion. A timeout was done.

We made an elliptical incision directly over the abdomen after I
injected 30 mL of 1% lidocaine mixed with 0.5% Marcaine. We then came
down through the subcutaneous tissues. I made a superior and inferior
flap, so I could get a large chunk of tissue. We took it off just above
the abdominal fascia with the Bovie. It was about a golf-ball sized
piece, and it should be sufficient. We then went ahead and established
hemostasis with the Bovie. This took a few minutes. We irrigated with
saline. Once everything was hemostatic, I injected a little bit more
local, and then we closed the fat with 3-0 Vicryl suture, followed by
3-0 Vicryl subdermal layer, followed by 3-0 nylon suture for the skin.
A sterile dressing was applied. All counts were correct.
 

such78

Expert
Messages
260
Location
Baldwin Park, CA
Best answers
0
I am newer to coding general surgery and was wondering if someone could give me direction on the proper way to code this.. here is the op note:
Diagnosis: rule out amyloidosis
Path report dx :
Soft tissue, abdominal fat pad biopsy
-- No evidence of amyloid deposition.
-- Congo red special stain is negative.


DESCRIPTION OF PROCEDURE: The patient's abdomen was prepped and draped
in sterile fashion. A timeout was done.

We made an elliptical incision directly over the abdomen after I
injected 30 mL of 1% lidocaine mixed with 0.5% Marcaine. We then came
down through the subcutaneous tissues. I made a superior and inferior
flap, so I could get a large chunk of tissue. We took it off just above
the abdominal fascia with the Bovie
. It was about a golf-ball sized
piece, and it should be sufficient. We then went ahead and established
hemostasis with the Bovie. This took a few minutes. We irrigated with
saline. Once everything was hemostatic, I injected a little bit more
local, and then we closed the fat with 3-0 Vicryl suture, followed by
3-0 Vicryl subdermal layer, followed by 3-0 nylon suture for the skin.
A sterile dressing was applied. All counts were correct.
11104 - documented down to the subcutaneous tissue only. if within/behind abdominal cavity, use 49180.
 
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