Wiki excision if penile skin vein

catharine

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Hello All,
How would you code the following? This was done in office. I was thinking unspecified with a comparative of 55530? Any help would be appreciated.

Chief Complaint: Distal left prepuce 1.5 cm dilated penile thrombosed skin vein. Painful erections and ejaculation.

After verbal informed consent was obtained, the patient was placed supine, the distal shaft washed with Betadine, and I used 3.0 mL of 2% lidocaine underneath the distal left foreskin. We next made a transverse 2 cm incision, carefully dissecting down identifying a prepuce vein, with middle dilated portion. 4-0 Vicryl sutures were placed on either side. The vein was carefully removed with underlying cauterization of the soft tissue. Small portion, elliptical in nature 1.5 cm slice was removed. We used a two layer closure given his blood thinner usage using running 4-0 Vicryl on the undersurface of the soft tissue and a second on the actual skin. There is still excellent cosmetic reconstruction appearance, minimal discomfort. The patient was provided several days of antibiotics and full description of how to keep the region dry after a shower and apply antibiotic cream over the next week
 
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