CaroleF01
Networker
Thoughts on CPT code? Please?
Pathology states "SKIN AND SUBCUTANEOUS TISSUE WITH CYSTIC LESION LINED BY FIBROUS CONNECTIVE TISSUE WITH ACELLULAR INTRACYSTIC MATERIAL AND FOCAL
ACCUMULATION OF MYXOID MATERIAL IN CYST WALL (CLINICAL BURSAL CYST)"
Procedure Note:
Patient was placed on supine semi sitting position. Left shoulder/suprascapular area was prepped and draped in usual operative manner. Local anesthesia 1 % Xylo with epi was infiltrated around the cyst. Elliptical skin incision was made and deepened into the subcutaneous tissue. Dissection was carried around the cyst. However it was noted that this was not a sebaceous cyst but rather a bursa. After that this bursa with overlying skin was excised. At the base area opening in bursa 4-0 polysorb sutures were used to close the opening to prevent synovial leak if possible. Hemostasis was obtained. Wound was closed in layers - 4-0 polysorb for sub q and 4-0 Nylon for skin in interrupted fashion. 4 x 4 gauze dressing was applied. Bursa size was 4.5 cm and layered closure length was 5.5 cm. Patient tolerated procedure well and left the clinic in stable condition.
Pathology states "SKIN AND SUBCUTANEOUS TISSUE WITH CYSTIC LESION LINED BY FIBROUS CONNECTIVE TISSUE WITH ACELLULAR INTRACYSTIC MATERIAL AND FOCAL
ACCUMULATION OF MYXOID MATERIAL IN CYST WALL (CLINICAL BURSAL CYST)"
Procedure Note:
Patient was placed on supine semi sitting position. Left shoulder/suprascapular area was prepped and draped in usual operative manner. Local anesthesia 1 % Xylo with epi was infiltrated around the cyst. Elliptical skin incision was made and deepened into the subcutaneous tissue. Dissection was carried around the cyst. However it was noted that this was not a sebaceous cyst but rather a bursa. After that this bursa with overlying skin was excised. At the base area opening in bursa 4-0 polysorb sutures were used to close the opening to prevent synovial leak if possible. Hemostasis was obtained. Wound was closed in layers - 4-0 polysorb for sub q and 4-0 Nylon for skin in interrupted fashion. 4 x 4 gauze dressing was applied. Bursa size was 4.5 cm and layered closure length was 5.5 cm. Patient tolerated procedure well and left the clinic in stable condition.