TnRushFan
Networker
Hello everyone, any guidance will be appreciated.
Surgeon performed bilateral inguinal hernias and documented removal of part of cord lipoma on each side but only submitted a specimen for one side. Do I need pathology to code for bilateral? Should the right lipoma bundle since it was "incorporated" in the hernia? I was taught that if the surgeon didn't sent a specimen to pathology we could not code it.
Thank you in advance.
49505-50
55520-59-50
** right side
** dissection of the cord structures and what appeared to be a cord lipoma incorporated within an indirect inguinal hernia
** further isolated the presumed cord lipoma
** were able to transect a portion of this cord lipoma while reducing the vast majority of it back within the peritoneal cavity.
** indirect inguinal defect
** mesh plug
** incision on the right side was subsequently closed
** attention to the left side
** fat-containing structure
** We separated these 2 structures,
** identified this as a cord lipoma, transecting a small portion of this cord lipoma and subsequently reducing the remainder through
the deep inguinal ring into the peritoneal cavity.
** large indirect defect was noted
** placed 1 large plug and 1 patch
Gross description:
SOFT TISSUE, LEFT CORD LIPOMA, REPAIR:Received in formalin and labeled
with the patient's name, social security number, and "left cord lipoma"
Microscopic exam/diagnosis:
DIAGNOSIS:
SOFT TISSUE, LEFT SPERMATIC CORD, INGUINAL HERNIA REPAIR: LIPOMA.
Surgeon performed bilateral inguinal hernias and documented removal of part of cord lipoma on each side but only submitted a specimen for one side. Do I need pathology to code for bilateral? Should the right lipoma bundle since it was "incorporated" in the hernia? I was taught that if the surgeon didn't sent a specimen to pathology we could not code it.
Thank you in advance.
49505-50
55520-59-50
** right side
** dissection of the cord structures and what appeared to be a cord lipoma incorporated within an indirect inguinal hernia
** further isolated the presumed cord lipoma
** were able to transect a portion of this cord lipoma while reducing the vast majority of it back within the peritoneal cavity.
** indirect inguinal defect
** mesh plug
** incision on the right side was subsequently closed
** attention to the left side
** fat-containing structure
** We separated these 2 structures,
** identified this as a cord lipoma, transecting a small portion of this cord lipoma and subsequently reducing the remainder through
the deep inguinal ring into the peritoneal cavity.
** large indirect defect was noted
** placed 1 large plug and 1 patch
Gross description:
SOFT TISSUE, LEFT CORD LIPOMA, REPAIR:Received in formalin and labeled
with the patient's name, social security number, and "left cord lipoma"
Microscopic exam/diagnosis:
DIAGNOSIS:
SOFT TISSUE, LEFT SPERMATIC CORD, INGUINAL HERNIA REPAIR: LIPOMA.