tgomez12
New
I was hoping some one could help me.... I am having some trouble choosing which code would be correct. Here is what my op report is stating:
PREOPERATIVE DIAGNOSIS: Right infected sebaceous cyst.
POSTOPERATIVE DIAGNOSIS: Right infected sebaceous cyst.
OPERATION PERFORMED: Wide local neck excision of a 4.2 x 1.9 infected sebaceous cyst.
FINDINGS: The cyst ruptured deep to the platysma and actually had a considerable subcutaneous component that was much greater beneath the skin than above the kin.
REASON FOR OPERATION: This patient is a 75-year-old gentleman who has had a persistent recurrent infected sebaceous cyst. He is being brought to the operating room electively to widely excise it to hopefully prevent from entering any cystic component and then by removing a wide local excision to rearrange the tissue for cosmetic appearance.
DESCRIPTION OF PROCEDURE: This patient was brought to the operating room. In the holding area, I drew out my planned incision. It was much greater than the size of the cyst. He was brought to the operating room where he underwent sedation. Under sterile conditions, I injected the area with lidocaine with epinephrine 1:100,000, total of 9 mL. I widely excised the mass. I was able to undermine deep so that I could easily identify that there was a component of the cyst that went deep to the platysma and therefore I widely excised that as well and stayed deep to any cystic component. The cyst also extended superiorly and I was very careful not to enter the cyst and keep a rim of fat and tissue around that area. Once the cyst was removed, I irrigated the area. I undermined the platysma as best as I could and reapproximated it with 3-0 chromic. The subcutaneous tissue was closed with 3-0 chromic and the skin was closed with running 5-0 Prolene. He tolerated the procedure well.
I want to code with 21552 but not sure if 14040 or 11426 is the better code.
Thank you,
tgomez12
PREOPERATIVE DIAGNOSIS: Right infected sebaceous cyst.
POSTOPERATIVE DIAGNOSIS: Right infected sebaceous cyst.
OPERATION PERFORMED: Wide local neck excision of a 4.2 x 1.9 infected sebaceous cyst.
FINDINGS: The cyst ruptured deep to the platysma and actually had a considerable subcutaneous component that was much greater beneath the skin than above the kin.
REASON FOR OPERATION: This patient is a 75-year-old gentleman who has had a persistent recurrent infected sebaceous cyst. He is being brought to the operating room electively to widely excise it to hopefully prevent from entering any cystic component and then by removing a wide local excision to rearrange the tissue for cosmetic appearance.
DESCRIPTION OF PROCEDURE: This patient was brought to the operating room. In the holding area, I drew out my planned incision. It was much greater than the size of the cyst. He was brought to the operating room where he underwent sedation. Under sterile conditions, I injected the area with lidocaine with epinephrine 1:100,000, total of 9 mL. I widely excised the mass. I was able to undermine deep so that I could easily identify that there was a component of the cyst that went deep to the platysma and therefore I widely excised that as well and stayed deep to any cystic component. The cyst also extended superiorly and I was very careful not to enter the cyst and keep a rim of fat and tissue around that area. Once the cyst was removed, I irrigated the area. I undermined the platysma as best as I could and reapproximated it with 3-0 chromic. The subcutaneous tissue was closed with 3-0 chromic and the skin was closed with running 5-0 Prolene. He tolerated the procedure well.
I want to code with 21552 but not sure if 14040 or 11426 is the better code.
Thank you,
tgomez12