Wiki help break this operative report down


True Blue
Marrero, LA
Best answers
Integumentary or musculoskeletal ? I ask this questions quite a few times. I seem to always get stuck on this area. Maybe its not enough documenation on most reports I read at work, really not sure . I went to bought a book called coding from the operative report- 2009-( by the way good price) and the book seems so easy, only because in reports it stated how deep, into muscle , soft tissue, SIZE, AND etc, but in the real world, its not always that easy when reading some of these reports, so here I want to get someone to point out what are the key words to look for when it does not specify deep or etc.

Dissection was carried down through the skin and subcutaneous tissue. What appeared to be a clinical endometrioma was removed
now does this mean integumentary ?

PREOPERATIVE DIAGNOSIS: Anterior abdominal wall masses x2.

POSTOPERATIVE DIAGNOSIS: Anterior abdominal wall masses x2.

PROCEDURES PERFORMED: 1. Excision of anterior abdominal wall mass greater than 5 cm.
2. Excision of anterior abdominal wall mass 2 cm.

OPERATIVE PROCEDURE: After appropriate informed consent was signed, the patient was taken to the operating room. She was transferred to the operating table and underwent general anesthesia with endotracheal intubation, the abdomen was prepped and draped in the normal fashion. An incision was made right of the abdomen over the previous abdominal wall mass, around 6 cm. . There was a smaller one below this and a small incision below this was made in the skin and also removed. The area was irrigated. It was sent to pathology for permanent sectioning. The wound was then closed in two layers with 3-0 Vicryl, the larger one was closed with 4-0 Vicryl in subcuticular fashion and 3-0 nylon was used on the other one. A sterile dressing was placed. The patient tolerated the procedure and transferred to the recovery room in stable condition.
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With the documentation that you have, it would be considered the integumentary system. I would educate your physician on better documentation. The revenue of the office could be impacted by this.