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Opinions on OP Note please

  1. #1
    Location
    Seacoast, Dover NH
    Posts
    74
    Question Opinions on OP Note please
    Medical Coding Books
    Hello - below is an OP note I received. I would appreciate feedback and opinions on how this should be coded:

    Preoperative Diagnosis: Atypical condyloma and squamous cell carcinoma in situ of the vulva

    Postoperative Diagnosis: Atypical condyloma and squamous cell carcinoma in situ of the vulva

    Anesthesia: Spinal

    Description of Procedure:
    An approximate 3 cm wide by 2.5 cm AP diameter of the condylomatous lesions in the posterior fourchette, extending from the right to the left and extending about a 1.5 cm to 2 cm from the midline on both sides. This area is extended to the hymenal ring and also within about 4 mm of the anus. This entire area was incised after the area was drawn with a marking pen.

    The underlying tissue, especially in the midline, was quite scarred secondary to episiotomies done in the past. There was no sphincter tissue noted in this area, which was significantly scarred. A sliver of tissue, approximately 1 cm long and about 5 mm wide, at 12 o'clock, right at the entrance of the vagina was taken, to allow undermining of the vaginal mucosa, so that the area could be closed without tension. The vagina was undermined for several centimeters up into the vaginal area, this was normal appearing mucosa.

    Gloves were changed and a rectal exam was done, which revealed no defect in the mucosa of the rectum, and no good sphincter tone in the rectal sphincter area. The scarred ends of the sphincter were dissected out, as if doing a 3rd degree repair and the scarred sphincter was then approximated at 12 o'clock with 2 sutures of 0-Vicryl. The mucosa was then approximated without any tension from the most caudal area, up towards the hymenal ring. At this point, this suture of 3-0 Vicryl was tied, and then the vaginal mucosa was brought down over this area, and extended out towards the perineum, to hopefully allow improved healing and less dyspareunia. The mucosa was sutured to the cut edges of the vulvar skin, and hemostasis was excellent at this point.

    The patient tolerated the procedure well and was sent to the recovery room in good condition.

    Thank you,
    Doss
    Last edited by dlashua; 08-05-2010 at 01:21 PM.

  2. #2
    Default Excision Malignant Lesion.
    Check 11623 & 13131 as CPT codes.
    233.32 & 078.11 ICD codes please check it helps you. Others also share their expertise.

    Quote Originally Posted by dlashua View Post
    Hello - below is an OP note I received. I would appreciate feedback and opinions on how this should be coded:

    Preoperative Diagnosis: Atypical condyloma and squamous cell carcinoma in situ of the vulva

    Postoperative Diagnosis: Atypical condyloma and squamous cell carcinoma in situ of the vulva

    Anesthesia: Spinal

    Description of Procedure:
    An approximate 3 cm wide by 2.5 cm AP diameter of the condylomatous lesions in the posterior fourchette, extending from the right to the left and extending abut a 1.5 cm to 2 cm from the midline on both sides. This area is extended to the hymenal ring and also within about 4 mm of the anus. This entire area was incised after the area was drawn with a marking pen.

    The underlying tissue, especially in the midline, was quite scarred secondary to episiotomies done in the past. There was no sphincter tissue noted in this area, which was significantly scarred. A sliver of tissue, approximately 1 cm long and about 5 mm wide, at 12 o'clock, right at the entrance of the vagina was taken, to allow undermining of the vaginal mucosa, so that the area could be closed without tension. The vagina was undermined for several centimeters up into the vaginal area, this was normal appearing mucosa.

    Gloves were changed and a rectal exam was done, which revealed no defect in the mucosa of the rectum, and no good sphincter tone in the rectal sphincter area. The scarred ends of the sphincter were dissected out, as if doing a 3rd degree repair and the scarred sphincter was then approximated at 12 o'clock with 2 sutures of 0-Vicryl. The mucosa was then approximated without any tension from the most caudal area, up towards the hymenal ring. At this point, this suture of 3-0 Vicryl was tied, and then the vaginal mucosa was brought down over this area, and extended out towards the perineum, to hopefully allow improved healing and less dyspareunia. The mucosa was sutured to the cut edges of the vulvar skin, and hemostasis was excellent at this point.

    The patient tolerated the procedure well and was sent to the recovery room in good condition.

    Thank you,
    Doss

  3. #3
    Location
    Seacoast, Dover NH
    Posts
    74
    Default
    My concern/confusion comes from the repair - I keep going back to the code for perineoplasty instead of the skin repair code because of how extensive it was. Any thoughts?

    Thank you,
    Doss

  4. Default
    Yes the repair part though seemingly 3degree tear repair, meaning perineorraphy, it was not the typical procedure of perineorraphy/plasty. vaginal mucosa brought to the perineal skin region, approximated and repaire;. this looks like an adjacent tissue transfer -one type of tissue brought to close the defect of another type of tissue -asort of primary and secondary defect closure-in terms of sqcms we should measure. So I am in favor of adjacent tissue Tranfer or rearrangement the most suitable code would be 14040. dont you think so?
    how do you account for the one benign and the other malignant- the atypia of condyloma and the ca in situ. how did you macroscopically separated both lesions without path report- where was the demarkation line/zone grossly;it seems to be intermingled; apypia of the condyloma turned malignancy?.so both are in lieu with malignancy for coding purpose atleast!!
    A confusing picture to demarakate the benign (though atypia) and Ca situin the same area.
    Any way this my openion.

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