such78
Expert
POSTOP DIAGNOSIS: Left preauricular cyst.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, patient was taken to the operating room, placed under monitored anesthesia care. The patient was prepped and draped in sterile
fashion. Approximately 4 cc of lidocaine with epinephrine was injected into the preauricular area. The previous infected site was erythematous and scarred down and, therefore, an elliptical incision was made
around the lesion measuring approximately 3 cm. The elliptical incision was made using a #15 blade, and using tenotomy scissors, the superficial layer was completely removed and sent to Pathology labeled
as preauricular cyst. Additionally, attention was paid to the left preauricular pit where a lacrimal probe was used to probe the fistula tract. The tract was followed, and using a #15 blade, the pit was excised
and dissected down to the tragal cartilage. The entire specimen was removed and sent to Pathology for permanent section. Hemostasis was achieved using needle-tip Bovie. The deep dermal layers were then reapproximated using 3-0 Vicryl suture. The superficial layer was then reapproximated using 5-0 nylon. 6-0 fast-absorbing plain gut was used at the preauricular sinus area. Benzoin and Steri-Strips were then placed on top of the wound.
Is it correct to assign 42815 for preauricular cyst removal , and the excised was down to the tragal cartilage?
or assign 11443- begin skin excision and 12052- intermediate repair since the surgeon did not performed via parotid approach?
Thank you for advice.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, patient was taken to the operating room, placed under monitored anesthesia care. The patient was prepped and draped in sterile
fashion. Approximately 4 cc of lidocaine with epinephrine was injected into the preauricular area. The previous infected site was erythematous and scarred down and, therefore, an elliptical incision was made
around the lesion measuring approximately 3 cm. The elliptical incision was made using a #15 blade, and using tenotomy scissors, the superficial layer was completely removed and sent to Pathology labeled
as preauricular cyst. Additionally, attention was paid to the left preauricular pit where a lacrimal probe was used to probe the fistula tract. The tract was followed, and using a #15 blade, the pit was excised
and dissected down to the tragal cartilage. The entire specimen was removed and sent to Pathology for permanent section. Hemostasis was achieved using needle-tip Bovie. The deep dermal layers were then reapproximated using 3-0 Vicryl suture. The superficial layer was then reapproximated using 5-0 nylon. 6-0 fast-absorbing plain gut was used at the preauricular sinus area. Benzoin and Steri-Strips were then placed on top of the wound.
Is it correct to assign 42815 for preauricular cyst removal , and the excised was down to the tragal cartilage?
or assign 11443- begin skin excision and 12052- intermediate repair since the surgeon did not performed via parotid approach?
Thank you for advice.