WOULD 40812 BE A GOOD CHOICE FOR THIS.PATH CAME BACK AS A MUCOCELE OF LOWER LIP. Doc office says 40490 not surewhich one is right ? Any suggestions
POSTOPERATIVE DIAGNOSIS: Lesion of lower lip.
OPERATION: Excision of lesion lower lip.
.HISTORY: This patient had a persistent cystic lesion of the buccal surface of the lower lip.
FINDINGS: 1 cm cystic lesion buccal surface of the lower lip, to the right of the midline.
DESCRIPTION OF PROCEDURE:
After satisfactory anesthesia was established, prep and drape was performed and the lower lip was everted. The lesion was excised with sharp dissection. Mucoid fluid filled the lesion. Minimal bleeding was controlled with bipolar cautery. The vertical incision was closed with interrupted 4-0 chromic catgut suture. The patient was then extubated and sent to the recovery room in stable condition.
I would go with 40812 and 528.9
He everted the lip and excised on the buccal surface of lip, with simple closure. Just about textbook.
1. Excision of lesion of mucosa and submucosa, vestibule of mouth;
40810, 40812, 40814 or 40816 depending on the extent of the surgery and repair
2. Biopsy, vestibule of mouth
3. Marsupialization of the Lesion:
40801 incision of cyst, complicated
He did not just take a biopsy.