AN2114
Guru
The doctor removed a forehead mass that went to the skull and complex multilayer closure. The codes I found for forehead mass are 21011-21014 but none of those codes involve the bone. I also looked at code 11420. The doctor is waiting for the pathology report but he believes it might be a dermoid cyst. I'm not sure if I should use the codes I mentioned and add modifier 22 since he excised down to the skull or if anyone knows a better code.
Here is the op report:
Postoperative diagnosis: Midline congenital forehead mass
Procedure: Excision of deep congenital midline forehead mass with track to skull and complex multilayer closure.
Findings: 3cm multilobular midline forehead mass extending to the skull and causing a divot in the bone.
Details:
Patient was taken to surgery induced with general anesthesia and intubated. The mass was identified and the surrounding skin was infiltrated with 4cc of 1% Xylocaine with epinephrine 1:100,000. The area was sterilely prepped and draped. An elliptical 2cm horizontal incision was made over the punctum that was overlying the mass. The mass was identified to be consistent with multilobular cystic midline mass extending all the way to the bone. This was dissected sharply away from it's surrounding attachments with care to not violate the capsule through skin subcutaneous fat, muscles and down through periosteum. The mass extended all the way to the frontal bone. There was divot in the bone where the mass orginated. The mass was excised and dissociated directly from the bone with careful dissection. The stalk was tied off and passed off to be sent for pathology. The mass was 3.5 cm. The wound was irrigated with sterile water and bleeding was controlled with bipolar cautery and bovie. The deep dermal and muscular layers were closed with 3-0 vicryl suture, and the skin was reapproximated with 5-0 monocryl in a subcuticular. The incision was dressed with mastisol and steri-strips. A pressure dressing was applied. Patient was returned to the care of the anesthesia team and then transferred to PACU in a stable condition.
Here is the op report:
Postoperative diagnosis: Midline congenital forehead mass
Procedure: Excision of deep congenital midline forehead mass with track to skull and complex multilayer closure.
Findings: 3cm multilobular midline forehead mass extending to the skull and causing a divot in the bone.
Details:
Patient was taken to surgery induced with general anesthesia and intubated. The mass was identified and the surrounding skin was infiltrated with 4cc of 1% Xylocaine with epinephrine 1:100,000. The area was sterilely prepped and draped. An elliptical 2cm horizontal incision was made over the punctum that was overlying the mass. The mass was identified to be consistent with multilobular cystic midline mass extending all the way to the bone. This was dissected sharply away from it's surrounding attachments with care to not violate the capsule through skin subcutaneous fat, muscles and down through periosteum. The mass extended all the way to the frontal bone. There was divot in the bone where the mass orginated. The mass was excised and dissociated directly from the bone with careful dissection. The stalk was tied off and passed off to be sent for pathology. The mass was 3.5 cm. The wound was irrigated with sterile water and bleeding was controlled with bipolar cautery and bovie. The deep dermal and muscular layers were closed with 3-0 vicryl suture, and the skin was reapproximated with 5-0 monocryl in a subcuticular. The incision was dressed with mastisol and steri-strips. A pressure dressing was applied. Patient was returned to the care of the anesthesia team and then transferred to PACU in a stable condition.