AT2728
Expert
Please see below op report-path came back as lipoma. I was looking at codes 21012 and 21014-tumor was noted greated the 2cm. However, hospital is going with unlisted since report states attached to calvarium. I'm wondering however, if 21011-21014 would be appropriate since "nothing" was performed on the bone itself. Also, since to the bone I was looking at 21014. I would appreciate guidance and opinions on this one!
The patient was taken to the operating room, placed in the supine position, had his forehead prepped and draped in the usual sterile fashion. 1% Lidocaine with Epinephrine was used for local anesthesia. #15 Bard Parker blade was then used to make a transverse 3 cm incision over this soft tissue tumor. This was carried through the subcutaneous tissue down to the tumor itself that was found to be well encapsulated and attached to the calvarium. It was completely excised and submitted for pathologic evaluation. Hemostasis was achieved with electrocautery and closure was done in 2 layers using #3-0 Vicryl proximally to the subcutaneous tissue and skin was then closed with a running #5-0 Nylon suture.
April R
The patient was taken to the operating room, placed in the supine position, had his forehead prepped and draped in the usual sterile fashion. 1% Lidocaine with Epinephrine was used for local anesthesia. #15 Bard Parker blade was then used to make a transverse 3 cm incision over this soft tissue tumor. This was carried through the subcutaneous tissue down to the tumor itself that was found to be well encapsulated and attached to the calvarium. It was completely excised and submitted for pathologic evaluation. Hemostasis was achieved with electrocautery and closure was done in 2 layers using #3-0 Vicryl proximally to the subcutaneous tissue and skin was then closed with a running #5-0 Nylon suture.
April R