stacymhennessey
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I'm new-ish to coding and I can generally figure things out, but this one is making me crazy. I'm coding for the ASC where the surgery was done, and it was originally sent to us as dx L89.9 and cpt 11440, but the outside coding company that we use occasionally came back with dx L08.9 & L90.5 and cpt 30124. Here is the op report info. I appreciate any help you can give me...
PREOPERATIVE DIAGNOSIS: DRAINING LESION NASAL DORSUM.
POSTOPERATIVE DIAGNOSIS: DRAINING LESION NASAL DORSUM, PROBABLE DERMOID CYST.
TITLE OF OPERATION: EXCISION OF CYSTIC TRACT AND CYST INVOLVING THE SUBCUTANEOUS ASPECTS OF THE NASAL DORSUM.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position on the operating table. After a satisfactory level of general anesthesia had been achieved, the patient was prepped and draped in the routine fashion for external nasal surgery. The area surrounding the lesion in question was then infiltrated with approximately 0.5 mL of 1% Xylocaine and 1:100,000 dilution of epinephrine to enhance perioperative hemostasis, as well as provide postoperative analgesia. After the patient had been prepped and draped then, a lacrimal probe was inserted into the dimple over the nasal dorsum and followed to a blind end within the subcutaneous tissues of the nose toward the nasal glabella. An elliptical incision was then made around the dimple itself and the soft tissue dissected around the lacrimal probe. This was carried down to the level of the nasal bones, where a larger cystic structure was encountered and opened. This was removed sharply from the nasal bones utilizing iris scissors. After what was felt to be a complete excision of the cystic lesion then the base of the wound was thoroughly cauterized using a needle tip Bovie. The wound was then irrigated with saline solution and closed in the following fashion: Subcutaneous tissue were approximated utilizing 5-0 chromic catgut suture. The skin was closed utilizing interrupted vertical mattress sutures of 5-0 nylon. Steri-Strips were then placed over the wound and the procedure terminated. Specimen was sent for permanent histological identification. The patient was then allowed to awaken from his anesthesia, was extubated on the operating table and taken to the PACU where he arrived in satisfactory condition maintaining his own protective reflexes. The blood loss during this procedure was no more than 10 mL with replacement with crystalloid fluid only. There were no drains and no intraoperative complications. It should be mentioned that the anesthesia was delivered LMA.
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The pathoology report reads: Nasal lesion with tract, removal: Minimal non-specific chronic inflammation and fibrosis.
- Reactive skin with underlying sebaceous units and skeletal muscle.
Please help. Thank you!
PREOPERATIVE DIAGNOSIS: DRAINING LESION NASAL DORSUM.
POSTOPERATIVE DIAGNOSIS: DRAINING LESION NASAL DORSUM, PROBABLE DERMOID CYST.
TITLE OF OPERATION: EXCISION OF CYSTIC TRACT AND CYST INVOLVING THE SUBCUTANEOUS ASPECTS OF THE NASAL DORSUM.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed in the supine position on the operating table. After a satisfactory level of general anesthesia had been achieved, the patient was prepped and draped in the routine fashion for external nasal surgery. The area surrounding the lesion in question was then infiltrated with approximately 0.5 mL of 1% Xylocaine and 1:100,000 dilution of epinephrine to enhance perioperative hemostasis, as well as provide postoperative analgesia. After the patient had been prepped and draped then, a lacrimal probe was inserted into the dimple over the nasal dorsum and followed to a blind end within the subcutaneous tissues of the nose toward the nasal glabella. An elliptical incision was then made around the dimple itself and the soft tissue dissected around the lacrimal probe. This was carried down to the level of the nasal bones, where a larger cystic structure was encountered and opened. This was removed sharply from the nasal bones utilizing iris scissors. After what was felt to be a complete excision of the cystic lesion then the base of the wound was thoroughly cauterized using a needle tip Bovie. The wound was then irrigated with saline solution and closed in the following fashion: Subcutaneous tissue were approximated utilizing 5-0 chromic catgut suture. The skin was closed utilizing interrupted vertical mattress sutures of 5-0 nylon. Steri-Strips were then placed over the wound and the procedure terminated. Specimen was sent for permanent histological identification. The patient was then allowed to awaken from his anesthesia, was extubated on the operating table and taken to the PACU where he arrived in satisfactory condition maintaining his own protective reflexes. The blood loss during this procedure was no more than 10 mL with replacement with crystalloid fluid only. There were no drains and no intraoperative complications. It should be mentioned that the anesthesia was delivered LMA.
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The pathoology report reads: Nasal lesion with tract, removal: Minimal non-specific chronic inflammation and fibrosis.
- Reactive skin with underlying sebaceous units and skeletal muscle.
Please help. Thank you!