brandyleigh23

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Rocky Mount, NC
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Need help with this in office procedure note. :confused:

Provider is billing 21026/22 but this seems too invasive for an office setting...

Also, if we were excising bone it would seem we would give more than local anesthetic.
The provider used local anesthesia 1% Lidocaine and .25% Marcaine.


Dx: R22.0 (Mass on forehead)

Description of Procedure:

The area was cleansed with alcohol swabs. It was locally blocked with anesthetic. the area was then prepped with Betadine and draped in a sterile fashion. Markings were drawn on the skin for the incision. Dissection was made through the underlying subcutaneous tissue. The muscle was then spread around exposing the mass. The mass was palpated and noted to be non-mobile. The mass was appeared completely calcified. I used a rongeur in order to remove the bony protuberance. The Roger was to remove the bony prominence until it was noted to be near the same height as the rest of the calvarium. The edges were widely undermined and advanced toward each other . The incision was extended to advance the skin flaps. this allowed for a tension free closure and proper alignment of the skin edges. Electric cautery was used to obtain hemostasis. The wound was irrigated with hydrogen peroxide followed by saline. The wound was noted to be hemostatic. The wound was reapproximated in a layered fashion with 5-0 monocryl for the muscular layer and deep tissue layer. 6-0 prolene was used to reapproximate the skin. The wound was cleansed with saline. Steri-Strips were placed over the incision. The patient tolerated the procedure well.
 
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