Draining cystic mass of scrotum and perineum


Waukee, IA
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Excision of cystic mass of scrotum and perineum, 4-5cm

I began be identifying the opening, which by squeezing the inflamed tissue I could see a little purulence come from.

I made an incision with a U-shaped tab trying to stay on the midline with the incision and then the tab was around the tract. I dissected through the dermis with Bovie electrocautery after the blade, and had infiltrated with a lidocaine and Marcaine mixture as well. I identified the sac with inflammation around it and sharply dissected this out. I assured that I was around this. I did place a Foley as it did appear to go deepand I wanted to verify where the urethra was. As I made my way cicumferentially around this, I did notice that it came ver close to the skin as I went laterally on the right, so I felt that I would need to excise this later. Once I had excised all of the lesion, using stay sutures in retraction with Allises to verify that I had removed all of the abscess vaicty and pocket, I then evaluated and did excise some of the right perineal skin.

Once this was done, I assured good hemostatsis in the base and then close in multiple layers with interrupted 3-0 Vicryl. I then close the perineal incision with 3-0 nylon in an interrupted fashion. We put fluffs and mesh pants on, and we removed the Foley cather at the end. This conclufed the procedure, which the patient tolerated well. The total pocket was approximately 5 to 8 cm.

The path report came back as skin and sucutaneous tissue with reactive fibrosis, acute and chronic inflammation, foreign body giant cell reaction and fat necrosis.

Do I code this as 11426 or as 54700 vs 55100??
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I would suggest the following coding for your clinical scenario:
11426 for the removal of the lesion
12044 for the multiple layer closure