Soft tissue mass on leg

codedog

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Not sure how to code this. Want to code it as a soft tissue mass on leg 27618 but when I path report says abscess- sctions of skin with underlying soft tissue reveal a abscess contain neutrophils surrounded by inflamed granulation tissue. NO granulomas are identified.,but reading report seems like soft tissue tumor ? not sure , any ideas ?



POSTOPERATIVE DIAGNOSIS: Soft tissue mass, left lower leg.

PROCEDURE PERFORMED: Excisional biopsy of soft tissue mass, left lower leg.

ANESTHESIA: MAC.
CLINICAL HISTORY: patient with an enlarging symptomatic mass on left lower leg couple of centimeters anterior to the previous healed incision from an orthopedic procedure. This does not appear to be a hardware infection.

PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in supine position. The left lower leg was prepped and draped in a sterile fashion. 10 cc of 1% lidocaine with epinephrine were injected for local anesthesia. An elliptical incision was made directly over the mass parallel to the previous incision to get down to it. Using electrocautery, it was excised with grossly negative margins. Grossly it was consistent with a scar. There were no signs of infection. There was no hardware or bone visible. The wound was irrigated with normal saline. Subcutaneous tissue was closed with interrupted 3-0 Vicryl sutures and interrupted 3-0 Nylon was used to close the skin. Sterile dressing was applied. The patient tolerated the procedure well.
 

codedog

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another coder told me to use 276189 since it was soft tissue and 3cm or smaller since no size was dictated. Alo was to to use 238.1-uncertain behavior of soft tissue. Does this seem ok ?
 
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