One of our doctors saw a patient in the office for a "left groin mass". He had a history of having vein stripping in the left leg and has had problems with the left groin, it has some bluish discoloration, it was subcutaneous. The doctor did an excisional biopsy in the office. His procedure note states: "Left groin mass biopsy"...and elliptical incision was made around a mass in the left groin....he goes on to state that there were multiple venous feeders going into this and these were individually ligated with 3-0 Vicryl suture ligation. After excising the mass, the wound was closed and dressing applied. The pathology states this was 2.3 x 1.5 x .9cm.."extensive soft tissue hemorrhage with loose fibroblastic proliferation, most consistent with organizing thrombus". I am stumped as to how to code this procedure....any suggestions?
Susan Smith, CPC
Susan Smith, CPC