NEED HELP - This case was booked as a herina repair, but as you read no herina was found. Path report stated that 3 lymph noded were identified and that the entire specimen was submitted in three cassette- reactive hyperlasia . Looking at cpt code 38500,would this be a good choice.please help-thanks
PREOPERATIVE DIAGNOSES: Right groin mass and inguinal hernia.
POSTOPERATIVE DIAGNOSES: No evidence of right inguinal hernia, right groin mass, and lymphadenopathy.
OPERATION: Right groin exploration and removal of lymphadenopathy.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table, underwent general anesthesia with successful LMA. The right groin was prepped and draped in normal fashion. Time-out was performed prior to making skin incision and antibiotics had been given prior to making skin incision. The right groin incision was made for around 4 to 5 cm. Dissection was carried down through skin and subcutaneous tissue. Two Gelpi’s were placed. External oblique fascia was identified, and below this at the level of the inguinal ligament but not going through the fascia, there appeared to be some discolored lymph nodes, like blue lymph nodes from a tattoo perhaps, maybe ink from a tattoo, a ______ tattoo, which is exactly what these were. There were about two to three of these. Clips were placed around them and they were removed. The area was irrigated. There was found to be no evidence of hernia at all. There was no inguinal hernia or femoral hernia. The Scarpa’s was closed and then skin was closed with 4-0 running Vicryl. Sterile dressing was placed. The patient tolerated the procedure and was transferred to the recovery room in stable condition.
Last edited by codedog; 06-06-2011 at 11:04 AM.
I would use 38500 with 785.6.
3x or just once?,i guess one ncision so once?
Number of nodes excised on one site (superficial here) does not alter -The description of the code 38500 itself says " lymph node(s)".
doctold meto check out 38760 ,not sure about this,one sdtill want to go with