no size

codedog

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What do you do when there is no size of cyst on operative report. ?Also this particular case was an excision of epidermal cyst and booking was 27327 excision of thigh mass less than 3 cm , I spoke to someone and they said leave it as 27327 because it states 3cm or less , but I think it should be integumentary code 1140x only because its a cyst not a tumor, Am I right ?

CLINICAL HISTORY: what appears to be an epidermal inclusion cyst on his left thigh, which has repeatedly got infected. It does not appear infected now.

PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating table in supine position with the left leg flexed at the knee and the left inner thigh was prepped and draped in sterile fashion. A 15 cc of 1% lidocaine with epinephrine was injected for local anesthesia. A longitudinal elliptical incision was made around the mass. Sharp dissection was used to dissect trough the superficial subcutaneous tissue to excise the mass with grossly negative margins. There was no sign of infection. Hemostasis was achieved with electrocautery. Subcutaneous tissue was closed with two interrupted 3-0 Vicryl sutures and 3-0 nylon horizontal mattress and simple sutures were used to bring the edges of the skin together. There was no tension. A sterile dressing was applied. The wound was irrigated before closing and was hemostatic.




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