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Excision Fibroma Plantar Aspect

  1. #1
    Unhappy Excision Fibroma Plantar Aspect
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    I am having trouble coding this excision of a fibroma on the plantar aspect of the left foot. In the op report the pt had an old excision that they recut and found the fibrous tissue and a mass so I am just alittle confused on how to code this if anyone has any suggestions that would be great thanks

    Jill

  2. Default
    It may depend upon how deep the surgeon had to go. Double check your path report as well.

    ~L
    CPC, CGSC, COSC

  3. #3
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    they didn't go deep and they didn't send anything out for pathology which is making it harder and I am not sure why they didn't send the mass out for a path

  4. #4
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    Quote Originally Posted by jilly78 View Post
    they didn't go deep and they didn't send anything out for pathology which is making it harder and I am not sure why they didn't send the mass out for a path

    can you post the note?

  5. #5
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    sure here is what is said

    Procedure: Excision Fibroma, Plantar Aspect left foot

    Attention was directed to the plantar aspect of the left foot over the 3rd MPJ area where approximately a 1.5 inch linear wound was present where he had previous surgery and the incision had dehisced. Via sharp and blunt dissection, the old incision was cut out with the large fibrous tissue along the edge. With examination, upon the distal medial portion of the wound, there appeared to be a fibrotic mass. Via sharp and blund dissection, this was excised. The wound was then copiously flushed and re-examined for any abnormal tissue. There was still some fibrous tissue along the lateral aspect of the old incision and this was excised as well. Again the wound was flushed. The skin was reapproximated utilizing 4-0 Prolene. Sterile fluff dressing was applied to the plantar aspect of the left foot.

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