Straddle injury w/ left labial laceration - please help!

kkanne1005

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I am in desperate need of help! Any assistance in coding this op note will be greatly appreciated! :eek:

PREOPERATIVE DIAGNOSIS: Straddle injury with left labial laceration and
subclitoral laceration.

POSTOPERATIVE DIAGNOSIS: Straddle injury with left labial laceration with no
urethral, vaginal or bladder injury noted after exam under anesthesia.

PROCEDURE PERFORMED Exam under anesthesia, repair of left labial laceration
and repair of subclitoral laceration.

COMPLICATIONS : None.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Less than 20 mL.


CONDITION: Stable.

DISPOSITION: The patient was taken to the recovery room in stable condition.

OPERATIVE SUMMARY: The patient was placed on the operating table in the
supine position and legs placed in frogleg position. Under general
anesthesia, examination revealed no urethral laceration. The laceration began
at the superior margin of the left labia majora extending subclitoral and
extended to the right labia majora. Interrupted 4-0 chromic sutures were
placed to close the defect and hemostasis was adequate. It was injected with
dilute solution of Marcaine and the patient was taken to the recovery room in
stable condition.
 

skanderson

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Take a look at CPT 13131 (goes according to size of laceration(s) and look at diagnosis 878._
 
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