caskln1
Contributor
Dr coded 21933 w/ 13011 & 13012.... What I am struggling with is the ASC coder only coded the 21933 as they state that the complex repair is bundled into 21933 and that adding mod 59 is not necessary as the Dr was going to repair/close the excision & insert a drain anyways and the area being repaired is not a separate procedure or location. Here is the op report, please advise.......
PREOPERATIVE DIAGNOSIS: Right axillary mass, 15 cm.
POSTOPERATIVE DIAGNOSIS: Right axillary mass, 15 cm.
PROCEDURES PERFORMED:
1. Excision of right axillary mass, 15 cm, deep in the subfascial
2. Complex repair, right axilla, 10 cm, requiring excision of redundant skin
for primary repair.
INDICATIONS: The patient presented to my office with an enlarging right
axillary mass. We discussed risks, benefits and alternatives of excision of
this lesion. The patient understood the risks of infection, bleeding, poor
scarring, damage to surrounding structures, recurrence of the lesion, fluid
collections, hematoma formation and general dissatisfaction with the result.
He understood this. He wished to proceed. Informed consent was obtained.
PROCEDURE IN DETAIL: The patient was seen and marked in the preoperative
holding area. He was then brought to the Operating Room and placed supine on
the operating room table. Bilateral sequential compression devices were
placed. General anesthetic was then administered and the airway was secured.
The patient was then placed into the left lateral decubitus position on a
beanbag. All pressure points were padded appropriately. The right axillary
region was then prepped and draped in standard surgical fashion.
I began by infiltrating the area with 20 mL of a 50:50 mixture of 1% lidocaine
and 0.25% Marcaine with epinephrine. After appropriate time was allowed for
the anesthetic to take effect, the area was then prepped and draped in the
standard surgical fashion. I incised the skin with a 10 blade. An
approximate 10 cm incision was made. I then dissected down with Bovie
electrocautery. Deep to the Scarpa's fascia, I identified the lesion. The
lesion appeared to be fatty in nature. This was dissected circumferentially
with a combination of sharp and blunt dissection. This mass was then removed
in its entirety and passed off the field as specimen. At this time, the skin
edges were quite redundant. I then tailor-tacked this then overlapped. The
areas of skin excess were then sharply excised. At this time, I placed a
single #19-French drain in the right axilla. This was secured with a 3-0
nylon suture. I then irrigated the area copiously. Meticulous hemostasis was
achieved with the Bovie electrocautery. I then closed the deep fascia with
3-0 Monocryl. I then closed the deep dermis with 3-0 Monocryl. I then closed
the skin with 4-0 Monocryl in a running intracuticular fashion. Steri-Strips
were applied. A gently compressive dressing was fashioned. The patient was
undraped. The sponge, needle and instrument counts were correct. He was then
awakened from his general anesthetic in stable condition. He was transferred
to the Postoperative Care Unit breathing spontaneously.
COMPLICATIONS: None immediately apparent.
IMPLANTS: None.
DRAINS: One drain in the right axilla.
PREOPERATIVE DIAGNOSIS: Right axillary mass, 15 cm.
POSTOPERATIVE DIAGNOSIS: Right axillary mass, 15 cm.
PROCEDURES PERFORMED:
1. Excision of right axillary mass, 15 cm, deep in the subfascial
2. Complex repair, right axilla, 10 cm, requiring excision of redundant skin
for primary repair.
INDICATIONS: The patient presented to my office with an enlarging right
axillary mass. We discussed risks, benefits and alternatives of excision of
this lesion. The patient understood the risks of infection, bleeding, poor
scarring, damage to surrounding structures, recurrence of the lesion, fluid
collections, hematoma formation and general dissatisfaction with the result.
He understood this. He wished to proceed. Informed consent was obtained.
PROCEDURE IN DETAIL: The patient was seen and marked in the preoperative
holding area. He was then brought to the Operating Room and placed supine on
the operating room table. Bilateral sequential compression devices were
placed. General anesthetic was then administered and the airway was secured.
The patient was then placed into the left lateral decubitus position on a
beanbag. All pressure points were padded appropriately. The right axillary
region was then prepped and draped in standard surgical fashion.
I began by infiltrating the area with 20 mL of a 50:50 mixture of 1% lidocaine
and 0.25% Marcaine with epinephrine. After appropriate time was allowed for
the anesthetic to take effect, the area was then prepped and draped in the
standard surgical fashion. I incised the skin with a 10 blade. An
approximate 10 cm incision was made. I then dissected down with Bovie
electrocautery. Deep to the Scarpa's fascia, I identified the lesion. The
lesion appeared to be fatty in nature. This was dissected circumferentially
with a combination of sharp and blunt dissection. This mass was then removed
in its entirety and passed off the field as specimen. At this time, the skin
edges were quite redundant. I then tailor-tacked this then overlapped. The
areas of skin excess were then sharply excised. At this time, I placed a
single #19-French drain in the right axilla. This was secured with a 3-0
nylon suture. I then irrigated the area copiously. Meticulous hemostasis was
achieved with the Bovie electrocautery. I then closed the deep fascia with
3-0 Monocryl. I then closed the deep dermis with 3-0 Monocryl. I then closed
the skin with 4-0 Monocryl in a running intracuticular fashion. Steri-Strips
were applied. A gently compressive dressing was fashioned. The patient was
undraped. The sponge, needle and instrument counts were correct. He was then
awakened from his general anesthetic in stable condition. He was transferred
to the Postoperative Care Unit breathing spontaneously.
COMPLICATIONS: None immediately apparent.
IMPLANTS: None.
DRAINS: One drain in the right axilla.