gmarie1311
New
How would you code an incision and exploration (without any kind of excision) of a left calf nodule?
After informed consent was obtained, the area of the lesion was prepped and draped in standard sterile fashion with Chlorhexidine solution. Pre-emptive analgesia was applied with 1% lidocaine with epinephrine solution prior to incision. After adequate pain control was achieved, a 2 cm incision, enlarged to 2.75cm for better visibility, was made along lines of least tension, and dissection was carried out to muscle fascia, which revealed a palpable defect. At that time, Dr. came in and examined the patient as well. He agreed that the exam is consistent with a small muscle hernia. There is a small piece of fat protruding through the muscle defect. At that time, the risks and benefits of a closure without any release of tension was discussed and, given the high level of recurrence with such a procedure, the patient decided that he would like to postpone any procedure at this time. The incision was closed with 3-0 dermal monocryl sutures, Steri-strips were placed, covered with a Tegaderm, then a sterile bandage was applied, covered by a Tegaderm.
Would it just be the incision and drainage code 27603?
Thanks for any help you can provide!
After informed consent was obtained, the area of the lesion was prepped and draped in standard sterile fashion with Chlorhexidine solution. Pre-emptive analgesia was applied with 1% lidocaine with epinephrine solution prior to incision. After adequate pain control was achieved, a 2 cm incision, enlarged to 2.75cm for better visibility, was made along lines of least tension, and dissection was carried out to muscle fascia, which revealed a palpable defect. At that time, Dr. came in and examined the patient as well. He agreed that the exam is consistent with a small muscle hernia. There is a small piece of fat protruding through the muscle defect. At that time, the risks and benefits of a closure without any release of tension was discussed and, given the high level of recurrence with such a procedure, the patient decided that he would like to postpone any procedure at this time. The incision was closed with 3-0 dermal monocryl sutures, Steri-strips were placed, covered with a Tegaderm, then a sterile bandage was applied, covered by a Tegaderm.
Would it just be the incision and drainage code 27603?
Thanks for any help you can provide!