codedog
True Blue
2 different procedures, 2 different patients , but same doctor. From what i read are my codes correct?
POSTOPERATIVE DIAGNOSIS: Posterior thoracic and right arm mass. Clinically, the back mass is an epidermal inclusion cyst, right arm mass is a lipoma.
OPERATION: Excision of posterior thoracic and right arm mass.
.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, transferred to the operating table, underwent general anesthesia with successful endotracheal intubation, and was placed in prone position. Attention was first given to the back mass. The area had been marked in the preoperative holding area. An incision was made directly over the area for around 3 to 4 cm. Dissection was carried down through the skin and subcutaneous tissue. What appeared to be an old epidermal inclusion cyst was removed. It was around 3.5 to 4 cm. The entire mass was removed and sent to pathology for permanent section. Excellent hemostasis was noted to be obtained. The wound was closed with 3-0 nylon in horizontal mattress. Attention was given to the right forearm mass then. The area was incised for around 5 to 6 cm. Around a 3 to 4 cm mass was removed, appeared to be clinically a lipoma, with Bovie cauterization. It was right under the skin. Excellent hemostasis was noted to be obtained. The wound was closed with 3-0 nylon. Sterile dressing was placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
I codedthis as 11406 - - 706.2
and 11404 214.1
and the one below as 21930 ?,this one Iam not sure of ? no size and if also says cyst,so I tend to want to code 114xx with an intermediate repair, WHAT DO YOU THINK ?
POSTOPERATIVE DIAGNOSIS: Right upper back mass.
OPERATION: Excisional biopsy of right upper back mass.
CLINICAL HISTORY: A with a mass on right upper back consistent with an epidermal inclusion cyst, consented for biopsy.
PROCEDURE IN DETAIL:
The patient was brought into the operating room and placed on the operating table in the prone position. The right upper back was prepped and draped in sterile fashion. 7 cc of 1% lidocaine with epinephrine were injected for local anesthesia. An elliptical incision was made over the mass with the #15 blade to excise, with grossly negative margins. There was no sign of infection. The wound was irrigated with normal saline. The wound was inspected and found to be hemostatic. The subcutaneous tissue was closed with interrupted 3-0 Vicryl and 3-0 nylon horizontal mattress and simple sutures were used to close the skin. The edges of the skin came together easily without tension. Sterile dressing was applied. The patient tolerated the procedure well.
POSTOPERATIVE DIAGNOSIS: Posterior thoracic and right arm mass. Clinically, the back mass is an epidermal inclusion cyst, right arm mass is a lipoma.
OPERATION: Excision of posterior thoracic and right arm mass.
.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, transferred to the operating table, underwent general anesthesia with successful endotracheal intubation, and was placed in prone position. Attention was first given to the back mass. The area had been marked in the preoperative holding area. An incision was made directly over the area for around 3 to 4 cm. Dissection was carried down through the skin and subcutaneous tissue. What appeared to be an old epidermal inclusion cyst was removed. It was around 3.5 to 4 cm. The entire mass was removed and sent to pathology for permanent section. Excellent hemostasis was noted to be obtained. The wound was closed with 3-0 nylon in horizontal mattress. Attention was given to the right forearm mass then. The area was incised for around 5 to 6 cm. Around a 3 to 4 cm mass was removed, appeared to be clinically a lipoma, with Bovie cauterization. It was right under the skin. Excellent hemostasis was noted to be obtained. The wound was closed with 3-0 nylon. Sterile dressing was placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
I codedthis as 11406 - - 706.2
and 11404 214.1
and the one below as 21930 ?,this one Iam not sure of ? no size and if also says cyst,so I tend to want to code 114xx with an intermediate repair, WHAT DO YOU THINK ?
POSTOPERATIVE DIAGNOSIS: Right upper back mass.
OPERATION: Excisional biopsy of right upper back mass.
CLINICAL HISTORY: A with a mass on right upper back consistent with an epidermal inclusion cyst, consented for biopsy.
PROCEDURE IN DETAIL:
The patient was brought into the operating room and placed on the operating table in the prone position. The right upper back was prepped and draped in sterile fashion. 7 cc of 1% lidocaine with epinephrine were injected for local anesthesia. An elliptical incision was made over the mass with the #15 blade to excise, with grossly negative margins. There was no sign of infection. The wound was irrigated with normal saline. The wound was inspected and found to be hemostatic. The subcutaneous tissue was closed with interrupted 3-0 Vicryl and 3-0 nylon horizontal mattress and simple sutures were used to close the skin. The edges of the skin came together easily without tension. Sterile dressing was applied. The patient tolerated the procedure well.
Last edited: