Wiki Help! Coding this Op report.

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Operation Performed: Left inguinal exploration and excision of lipoma.

A transverse inguinal incision was then made. This was carried to the subcutaneous tissues. I then placed one finger into the inguinal area via the scrotum. I pushed up the mass which had been quite tender and incised over that. It actually turned out to be a lipoma which was excised. Hemostasis was ensured using cautery.

I just need a code for the left inguinal exploration.

Any suggestions! Thanks.
 
Excision only

NOT my area of expertise, BUT ...

If this is all the op report, I'd code the excision of lipoma ONLY.

F Tessa Bartels, CPC, CEMC
 
The op note is a little unclear as to where the lipoma excision was made. If the lipoma is located on the spermatic cord you could consider 55520.
 
Help! Coding this Operative Report

Code 54560 is for undescended testis and that wasn't the reason for the exploration. I have a code for the excision of the Lipoma which was located anterior to the spermatic cord and distal to the external ring. I am just really confused on the Left Inguinal Exploration. I am leaning towards just coding for the excision of the Lipoma. Thanks so much for your comments and anything further would be appreciated.
 
I don't see the exploratory part of the op report in your post, so it that's the entire report I'd just code the lipoma excision.
 
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