ksb0211
Guest
I'm hoping for some confirmation on this one. I had one coder express the opinion that this should be billed as 49520 (recurrent inguinal hernia repair) due to the pathology report (below op report). Any input would be greatly appreciated. Thanks.
PREOPERATIVE DIAGNOSIS
Right inguinal hernia.
POSTOPERATIVE DIAGNOSIS
Mass right groin, possible spermatocele.
OPERATION PERFORMED
Exploration right groin, excision of mass.
DESCRIPTION OF PROCEDURE
The patient was taken to the OR. After induction of adequate general anesthesia, the patient was prepped with DuraPrep and draped sterilely. Perioperative antibiotics had been administered.
The initial incision was made in the right groin from the pubic tubercle superior laterally. Tissue was divided down to the level of the external oblique aponeurosis. Scarpa fascia was divided and venous structures were ligated. The superficial ring was surgically altered from previous repair. I entered the external oblique aponeurosis, the patient was noted to have a mass below this level. It was carefully dissected free from surrounding tissue. Venous structures as well as the vas were well identified. This mass appeared to have attachment extending towards the level of the deep ring. A definitive attachment to the vas was not seen. The attachment was then ligated with 3-0 Vicryl. The wound was inspected for hemostasis, it was well injected with Marcaine. There was no overt hernia appreciated. The external oblique aponeurosis was closed with interrupted 2-0 Vicryl suture. Subcutaneous tissue was closed with 3-0 Vicryl and a 4-0 Vicryl subcuticular stitch was utilized. Steri-Strips and Tegaderm applied. The patient tolerated the procedure well.
FYI: Pathology came back as "benign cystic lesion" It reads:
GROSS AND MICROSCOPIC EXAMINATION OF THIS SPECIMEN REVEALS A BENIGN CYSTIC LESION. THE CYSTIC WALL CONSISTS OF FIBROTIC APPEARING CONNECTIVE TISSUES WITH FOCAL AND SCATTERED, CHRONIC INFLAMMATORY INFILTRATES. FOCALLY, A FLAT EPITHELIAL LINING IS NOTED, LINING THE INTERIOR CYSTIC CAVITY SURFACE, LIKELY REPRESENTING MESOTHELIAL LINING ELEMENTS. HISTOLOGIC FINDINGS ARE CONSISTENT WITH TISSUES FROM A CLINICAL HERNIA SAC WITH CYST FORMATION. CLINICAL CORRELATION IS RECOMMENDED.
PREOPERATIVE DIAGNOSIS
Right inguinal hernia.
POSTOPERATIVE DIAGNOSIS
Mass right groin, possible spermatocele.
OPERATION PERFORMED
Exploration right groin, excision of mass.
DESCRIPTION OF PROCEDURE
The patient was taken to the OR. After induction of adequate general anesthesia, the patient was prepped with DuraPrep and draped sterilely. Perioperative antibiotics had been administered.
The initial incision was made in the right groin from the pubic tubercle superior laterally. Tissue was divided down to the level of the external oblique aponeurosis. Scarpa fascia was divided and venous structures were ligated. The superficial ring was surgically altered from previous repair. I entered the external oblique aponeurosis, the patient was noted to have a mass below this level. It was carefully dissected free from surrounding tissue. Venous structures as well as the vas were well identified. This mass appeared to have attachment extending towards the level of the deep ring. A definitive attachment to the vas was not seen. The attachment was then ligated with 3-0 Vicryl. The wound was inspected for hemostasis, it was well injected with Marcaine. There was no overt hernia appreciated. The external oblique aponeurosis was closed with interrupted 2-0 Vicryl suture. Subcutaneous tissue was closed with 3-0 Vicryl and a 4-0 Vicryl subcuticular stitch was utilized. Steri-Strips and Tegaderm applied. The patient tolerated the procedure well.
FYI: Pathology came back as "benign cystic lesion" It reads:
GROSS AND MICROSCOPIC EXAMINATION OF THIS SPECIMEN REVEALS A BENIGN CYSTIC LESION. THE CYSTIC WALL CONSISTS OF FIBROTIC APPEARING CONNECTIVE TISSUES WITH FOCAL AND SCATTERED, CHRONIC INFLAMMATORY INFILTRATES. FOCALLY, A FLAT EPITHELIAL LINING IS NOTED, LINING THE INTERIOR CYSTIC CAVITY SURFACE, LIKELY REPRESENTING MESOTHELIAL LINING ELEMENTS. HISTOLOGIC FINDINGS ARE CONSISTENT WITH TISSUES FROM A CLINICAL HERNIA SAC WITH CYST FORMATION. CLINICAL CORRELATION IS RECOMMENDED.