Does anyone have an idea for procedure code for this op report?? The code that was used for the pre-cert was 21930, but the Dr had already removed the mass that was there and was going back in to excise the margins. Thank you!
PREOPERATIVE DIAGNOSIS: abdominal wall metastasis
POSTOPERATIVE DIAGNOSIS: abdominal wall metastasis
PROCEDURE: wide excision of abdominal wall metastasis
SURGEON:
ASSISTANT: none
ANESTHESIA: local/MAC
INDICATIONS: This is an year old who presented with a 2 cm right lower quadrant abdominal wall mass. This was excised on 6/12/15 and determined to be anaplastic carcinoma consistent with a lung primary. The primary was found in the right upper lung lobe and will be treated with the Cyberknife. By PET scan, there are no other lesions, so we decided to widely re-excise the right lower quadrant abdominal wall metastasis in an attempt to achieve all clear margins.
FINDINGS: -
SPECIMENS: right lower quadrant abdominal wall mass.
ESTIMATED BLOOD LOSS: minimal
PROCEDURE: The patient was taken to the operating room and placed supine on the bed. The right lower quadrant abdominal wall was prepped and draped. The patient was sedated intravenously. After infiltrating with local anesthetic, an oblique 8 X 2 cm incision was made in the skin of the right lower quadrant abdominal wall, enclosing the scar of the prior excision. This incision was carried down through the subcutaneous tissues and fascia into the oblique musculature. A large specimen was excised while staying far from the old biopsy cavity and surrounding scar tissue. This involved excising a portion of muscle at the deep margin. The specimen was marked for margins with a long silk stitch on the lateral margin, a short silk stitch on the superior margin, and a double silk stitch on the deep (muscle) margin. A 7 flat JP drain was placed in the wound exiting through a stab wound in the right groin and secured to the skin at the exit site with a Vicryl suture. The deep tissues were reapposed with interrupted 3-0 Vicryl sutures. The skin was closed with a running 4-0 Vicryl subcuticular suture. Steristrips and a sterile dressing were applied. The drain was connected to a bulb suction device. The patient tolerated the procedure well. There were no evident complications.
PREOPERATIVE DIAGNOSIS: abdominal wall metastasis
POSTOPERATIVE DIAGNOSIS: abdominal wall metastasis
PROCEDURE: wide excision of abdominal wall metastasis
SURGEON:
ASSISTANT: none
ANESTHESIA: local/MAC
INDICATIONS: This is an year old who presented with a 2 cm right lower quadrant abdominal wall mass. This was excised on 6/12/15 and determined to be anaplastic carcinoma consistent with a lung primary. The primary was found in the right upper lung lobe and will be treated with the Cyberknife. By PET scan, there are no other lesions, so we decided to widely re-excise the right lower quadrant abdominal wall metastasis in an attempt to achieve all clear margins.
FINDINGS: -
SPECIMENS: right lower quadrant abdominal wall mass.
ESTIMATED BLOOD LOSS: minimal
PROCEDURE: The patient was taken to the operating room and placed supine on the bed. The right lower quadrant abdominal wall was prepped and draped. The patient was sedated intravenously. After infiltrating with local anesthetic, an oblique 8 X 2 cm incision was made in the skin of the right lower quadrant abdominal wall, enclosing the scar of the prior excision. This incision was carried down through the subcutaneous tissues and fascia into the oblique musculature. A large specimen was excised while staying far from the old biopsy cavity and surrounding scar tissue. This involved excising a portion of muscle at the deep margin. The specimen was marked for margins with a long silk stitch on the lateral margin, a short silk stitch on the superior margin, and a double silk stitch on the deep (muscle) margin. A 7 flat JP drain was placed in the wound exiting through a stab wound in the right groin and secured to the skin at the exit site with a Vicryl suture. The deep tissues were reapposed with interrupted 3-0 Vicryl sutures. The skin was closed with a running 4-0 Vicryl subcuticular suture. Steristrips and a sterile dressing were applied. The drain was connected to a bulb suction device. The patient tolerated the procedure well. There were no evident complications.