Wiki Laser of Vulvar and Anal Lesions


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Can someone help me with this surgery, I was under the understanding that you needed to list the quantity of lesions and the sizes of each lesion to be able to code this properly? Should I take back to physician to ask her to list that in op note?

Pre-Op diagnosis: Vulvar and anal condyloma

Post-Op diagnosis: same

Procedure: Laser excision of vulvar and anal condylomas

Anesthesia Type: General

EBL: Minimal

Specimen: Vulvar and anal condylomas

Complications: None

Disposition: To Recovery Room in stable condition

Findings: Multiple valvar and anal condyloma noted with the largest being 3 cm.

After general anesthesia was administered, the patient was in candy cane stirrups. She was then prepped and draped in a normal sterile fashion.

Her vaginal was inspected and using the laser on a power of 3 the vulvar and anal condylomas were excised. The larger condylomas were grasped with a curved stat and excised with a sterile blade. All specimens were sent to pathology. Hemostasis was achieved with cautery and with 3-0 vicryl in figure-of-eight sutures. After the procedure silver sulfadiazine was applied to the ares of excision. The patient tolerated the procedure well. All sponge, lap and needle counts were correct times two. The patient was transferred to the recovery room in satisfactory condition.