Wiki Exploration upper extremity-HELP!

[shellabell32]

Hi there,
Doctor did an exploration of the RT Upper Extremity thinking there would be a mass that he would excise. When he got in there he found that it was dilation of vein that was adherent to deeper structures. He closed it and is referring the patient to a vascular surgeon. I am not sure how to code it as he didn't do anything and it wasn't a penetrating wound or a foreign body.

Thanks for the help!!

 

[shellabell32]

Here is the OP note:

The right upper extremity and axilla were then prepped and draped in normal sterile fashion. A transverse incision was made over the mass and carried down through the subcutaneous tissue with electrocautery. With careful dissection, it was clear that this swollen mass was vein or part of a vein which appeared to be ecstatic. Further dissection revealed more than just one portion of the vein which was ecstatic and dilated. It appeared to be pretty adherent to deeper structures and therefore decision was made to not continue and to refer her to a vascular surgeon in the postoperative period.

Thanks again!