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Skin Removal after Vaginal Tear?!

anne32

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I have not idea what CPT code this should go under. HELP!


1. Vaginal skin remove. 2. Not a smoker.

HPI:
Midtown General HPI:
Pt has some protruding flesh from vagina thta has been bothersome and wants it excised. It resulted after delivery of last child and tear or episiotomy that allowed the "skin tag" - like protrusion. No pain or any other related sx. Desires the excision of this nuisance soft tissue.

ROS:
CONSTITUTIONAL:
Negative For Fever, Chills, N/V/D.
CARDIOLOGY:
Negative for dizziness, chest pain, shortness of breath.
RESPIRATORY:
Negative for shortness of breath, wheezing, persistent cough.


Gyn History: LMP 03/27/14. Abnormal Menstruations yes only 1 day. Dysmenorrhea no. Last Pap Smear Date 2 yr. Last Mammogram Date unsure. Abnormal Pap Smear unsure.

OB History: Total pregnancies 5. Total living children 5. Abortion(s) no.

Surgical History: ball on her L breast removed 1999.

Hospitalization/Major Diagnostic Procedure: ball on her L breast removed 1999.

Family History: Father: alive Mother: deceased 2 brother(s) , 4 sister(s) - healthy. 4 son(s) , 1 daughter(s) - healthy.

Social History: Smoking Status: Never. Chewing Tobacco: no. Caffeine use: no. Recreational Drug Use/ Substance Abuse: no. Alcohol: No. Occupation: Not working. Marital Status: Single. Lives With: with children. Education Level: High School. Language: French. Exercise: no. Country of Birth: Haiti. Self-Referral: No. Tobacco Exposure: No. Animal Exposures: no pets in the home.

Medications: None

Allergies: ibuprofen: face swollen,itchy, Alka-Seltzer Anti-Gas: face swollen,re eyes.


Objective:

Vitals: Pain scale 0, Wt 177 lb 6 oz, Ht 5 ft 4 in, BMI 30.44, BP 110/61, Temp 98.3, RR 18, HR 70.

Examination:
General Examination:
General Appearance NAD, pleasant, alert and oriented, well groomed, well nourished and hydrated, answers questions appropriately. FEMALE GENITOURINARY: Small area of soft tissue, appears as polypated vaginal mucosas protruding slightly from vaginal opening.



Assessment:

Assessment:
1. Proud flesh - 701.5 (Primary)

Plan:

1. Proud flesh
After consent obtained and tome out observed pt was placed in lithotomy posisiotn after which, under sterile conditions, 1.5 cc 1% Lido with Epi wa sinfiltrated into the base of the polyp and 3 minutes was allowed with good anesthesia achieved. the base of the lesion was then tied off with 4-0 Ethilon suture material and excised usinng a sharp scissors. Minimal bleeding and no complications were experienced.
 
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