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Thread: lesion excision, lesion not found

  1. #1

    Default lesion excision, lesion not found

    AAPC: Back to School
    I have an op report that I am having dificulty is coding. If anyone can point me in the right direction, I would be extremely greatful. I could not identify any code for exploration of chest wall that would apply. Would it be appropriate to use (once I querry MD for size of his incision) the appropriate lesion excision code with modifer -53, and then add the appropriate intermediate closure code? Below is the op report.

    PROCEDURE: Exploration, right lateral chest wall.
    OPERATIVE TECHNIQUE: The patient was wheeled into the operating room, identified, and laid in the left lateral position on a beanbag. He was given intravenous sedation. The right lateral chest wall area was prepped and draped in the standard sterile fashion.

    The lung was palpable over the rib. I infiltrated the area with 0.25% Marcaine, 1% lidocaine, and made an incision, dissecting down to the level of the subcutaneous tissue. I could not identify a lump. I then dissected farther down into the muscle. I dissected within the layers of the muscle, but did not identify the lump. Further dissection would mean entering down toward the parietal pleura. I decided to stop the procedure at this time.

    Continued dissection on the same plane did not identify the lump.

    I then confirmed hemostasis, closed the subcutaneous tissue with 3-0 Vicryl sutures, and closed the skin with 4-0 Vicryl subcuticular stitches. The wounds were cleaned and dressings applied. The patient tolerated the procedure. He left the operating room in stable condition.

  2. #2


    I would go w/ 21899. He was down in the muscles.

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