tloeb
Networker
For the case copied below I am looking at unlisted 58999 and compare to 27043 adding 1.5 times RVU for the complexity OR 11426 with complex closure code 1313X (need more detail for length from provider). Because 11426 is a lesion from the skin I am leaning towards, unfortunately, the unlisted code. Any recommendations?
INDICATIONS: 65 y.o. female who presented with enlarging right perineal mass. Preop radiologist studies favored a solid smooth walled mass and preop biopsy was non-diagnostic. The patient was consented for a radical resection of the mass.
ESTIMATED BLOOD LOSS: 150 cc
FINDINGS:
EUA: Examination of the groins demonstrated an approximately 8 X 6 X 6 cm mobile solid feeling mass involving the right perineum under the skin of the labia extending along the right vaginal wall by about 8 cm proximal to the hymen, abutting the anterior rectum but not involving the rectal mucosa and extending laterally to involving the right lateral labial fat and musculature.
SPECIMENS:
1. Right perineal mass
PREPARATION:
With the patient in the high lithotomy position under anesthesia, the groins, lower abdomen, vulva and vagina were prepped and draped as a sterile field. The patient had voided preop and catheterization was not performed.
PROCEDURE:
An vertical incision was made from anterior to posterior in the right perineal skin in an area where the mass was immediately under the skin. It was incised with cautery down to the mass. The mass was smooth walled but it didn't "core" out with ease as the attachments to the perineal muscles and tissues were somewhat inflamed. With cautery and blunt dissection the mass was removed in its entirety from the perineal, para-rectal and paravaginal spaces. As we approached the rectum an operators hand was placed in the rectum and great care was taken to carefully dissecting the indurated tissue off of the anterior rectal wall without injury to the rectum. This was performed several times during the resection and after resection while sutures were placed for hemostasis. The resection took approximated 40 minutes to undertake and during the resection there was some leaking of partially clotted bloody fluid from the mass. It partially collapsed but was thick walled at this point and clearly not a purely solid mass. Once resected, the mass was sent to pathology, later returning as no evidence of malignancy, final pathology pending to define the distinct etiology.
After the specimen had been removed some there was some bleeding that was controlled with deep running 2-0 and 3- 0 Vicryl sutures to close the dead space and provide hemostasis by compressing the spaces. The rectal mucosa was noted to be entirely intact and the musculature overlying the rectum was re-approximated with 4-0 vicryl suture. Approximately 4-5 layers of sutures were placed in order to both obtain hemostasis and close the large defect that resulted from resection of the perineal mass. The skin edges were then reapproximated with 4-0 subcuticular monocryl suture. Triple antibiotic ointment was placed over the wound and a "compression" dressing was placed. For addition compression a towel was rolled and placed between her thighs over the wound with plans to place ice in the recovery room.
The patient then returned to the recovery room in excellent condition. Her husband was notified by telephone that the procedure was satisfactorily completed and no evidence of malignancy. He was also advised about the pressure dressing to remove tomorrow if it didn't fall off prior to that time.
INDICATIONS: 65 y.o. female who presented with enlarging right perineal mass. Preop radiologist studies favored a solid smooth walled mass and preop biopsy was non-diagnostic. The patient was consented for a radical resection of the mass.
ESTIMATED BLOOD LOSS: 150 cc
FINDINGS:
EUA: Examination of the groins demonstrated an approximately 8 X 6 X 6 cm mobile solid feeling mass involving the right perineum under the skin of the labia extending along the right vaginal wall by about 8 cm proximal to the hymen, abutting the anterior rectum but not involving the rectal mucosa and extending laterally to involving the right lateral labial fat and musculature.
SPECIMENS:
1. Right perineal mass
PREPARATION:
With the patient in the high lithotomy position under anesthesia, the groins, lower abdomen, vulva and vagina were prepped and draped as a sterile field. The patient had voided preop and catheterization was not performed.
PROCEDURE:
An vertical incision was made from anterior to posterior in the right perineal skin in an area where the mass was immediately under the skin. It was incised with cautery down to the mass. The mass was smooth walled but it didn't "core" out with ease as the attachments to the perineal muscles and tissues were somewhat inflamed. With cautery and blunt dissection the mass was removed in its entirety from the perineal, para-rectal and paravaginal spaces. As we approached the rectum an operators hand was placed in the rectum and great care was taken to carefully dissecting the indurated tissue off of the anterior rectal wall without injury to the rectum. This was performed several times during the resection and after resection while sutures were placed for hemostasis. The resection took approximated 40 minutes to undertake and during the resection there was some leaking of partially clotted bloody fluid from the mass. It partially collapsed but was thick walled at this point and clearly not a purely solid mass. Once resected, the mass was sent to pathology, later returning as no evidence of malignancy, final pathology pending to define the distinct etiology.
After the specimen had been removed some there was some bleeding that was controlled with deep running 2-0 and 3- 0 Vicryl sutures to close the dead space and provide hemostasis by compressing the spaces. The rectal mucosa was noted to be entirely intact and the musculature overlying the rectum was re-approximated with 4-0 vicryl suture. Approximately 4-5 layers of sutures were placed in order to both obtain hemostasis and close the large defect that resulted from resection of the perineal mass. The skin edges were then reapproximated with 4-0 subcuticular monocryl suture. Triple antibiotic ointment was placed over the wound and a "compression" dressing was placed. For addition compression a towel was rolled and placed between her thighs over the wound with plans to place ice in the recovery room.
The patient then returned to the recovery room in excellent condition. Her husband was notified by telephone that the procedure was satisfactorily completed and no evidence of malignancy. He was also advised about the pressure dressing to remove tomorrow if it didn't fall off prior to that time.
