jayne
Contributor
Help! This may seem easy, but I am getting some grief over this one:
POSTOPERATIVE DIAGNOSIS: A 6 x 10 cm lipomatous mass in the right lower quadrant of the anterior abdominal wall.
OPERATION: SURGICAL EXCISION OF A 6 X 10 CM SIZE BENIGN LIPOMATOUS MASS FROM THE ANTERIOR ABDOMINAL WALL RIGHT LOWER QUADRANT.
DETAILS OF THE PROCEDURE: The patient was given labetalol and hydralazine to bring his blood pressure down. In the course of a few minutes his blood pressure stabilized at 160. We were able to proceed with the surgical excision of this lipomatous mass. We anesthetized an ellipse of skin and because this mass had completely effaced the back of the dermis of the overlying skin, we resected quite a bit of skin with the underlying tumor. We anesthetized with 1% lidocaine local. We made an elliptical incision. The mass was then shelled out using cautery. Once the 6 x 10 cm lipomatous mass with overlying skin was surgically removed, we reconstructed the anterior abdominal wall with interrupted sutures of 2-0 Vicryl and interrupted skin staples.
I coded it to integumentary since he didn't mention the subq anywhere in the report, or closing the subq. Any help for this one?
POSTOPERATIVE DIAGNOSIS: A 6 x 10 cm lipomatous mass in the right lower quadrant of the anterior abdominal wall.
OPERATION: SURGICAL EXCISION OF A 6 X 10 CM SIZE BENIGN LIPOMATOUS MASS FROM THE ANTERIOR ABDOMINAL WALL RIGHT LOWER QUADRANT.
DETAILS OF THE PROCEDURE: The patient was given labetalol and hydralazine to bring his blood pressure down. In the course of a few minutes his blood pressure stabilized at 160. We were able to proceed with the surgical excision of this lipomatous mass. We anesthetized an ellipse of skin and because this mass had completely effaced the back of the dermis of the overlying skin, we resected quite a bit of skin with the underlying tumor. We anesthetized with 1% lidocaine local. We made an elliptical incision. The mass was then shelled out using cautery. Once the 6 x 10 cm lipomatous mass with overlying skin was surgically removed, we reconstructed the anterior abdominal wall with interrupted sutures of 2-0 Vicryl and interrupted skin staples.
I coded it to integumentary since he didn't mention the subq anywhere in the report, or closing the subq. Any help for this one?
