pravintc
Networker
indication: A female complaining of slow-growing mass under her right jaw that has been present for 2 years. A 1 cm firm slightly elevated subcu mass just under right side of mandible.
postop diagnosis: symptomatic right submandibular mass.
intraoperative findings: A pea-sized cystic lesion.
description of procedure: after prep/drape/general anesthesia using LMA device/time out taken. a 1-cm incision was made along skin lines directly over the palpable lesion. incision was carried down to level of subcu tissue. the lesion was circumferentially dissected out and evaluated and appeared to consistent with cystic lesion and sent to pathology. hemostasis was achieved using bovie cautery. there did not appear to be any nerves or important blood vessels in the immediate area. the wounds were closed in layers. the dermal layer was closed with 4-0 Vicryl in an interrupted manner and skin closed with 5-0 prolene in interrupted manner. the wound was cleaned and a sterile pressure dressing was applied. the patient tolerated the procedure well.
path report: Vascular channel with organizing thrombus.
I have a doubt between CPT 42440 and 21040. For 42440 no gland was involved and 21040 description says as mandibular enucleation or should i code 11441 and 12051 for intermediate repair.
please suggest.
postop diagnosis: symptomatic right submandibular mass.
intraoperative findings: A pea-sized cystic lesion.
description of procedure: after prep/drape/general anesthesia using LMA device/time out taken. a 1-cm incision was made along skin lines directly over the palpable lesion. incision was carried down to level of subcu tissue. the lesion was circumferentially dissected out and evaluated and appeared to consistent with cystic lesion and sent to pathology. hemostasis was achieved using bovie cautery. there did not appear to be any nerves or important blood vessels in the immediate area. the wounds were closed in layers. the dermal layer was closed with 4-0 Vicryl in an interrupted manner and skin closed with 5-0 prolene in interrupted manner. the wound was cleaned and a sterile pressure dressing was applied. the patient tolerated the procedure well.
path report: Vascular channel with organizing thrombus.
I have a doubt between CPT 42440 and 21040. For 42440 no gland was involved and 21040 description says as mandibular enucleation or should i code 11441 and 12051 for intermediate repair.
please suggest.
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