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Please help with short op-note!

  1. Question Please help with short op-note!
    Medical Coding Books
    Can someone please help me code this report?


    The keloid was first removed with the appropriate skin incision to do so. The skin incision was then taken down through subcutaneous tissue with bleeders clamped and bovied in the usual manner. Identifying the greater trochanter over it and about 4 cm beyond it, the tensor fascia lata was opened and then the vastus lateralis was split longitudinally to expose the plate from its most proximal end to the distal end. On the right side, there was a small degree of bone overlapping it, which was removed with an osteotome on the left. It was more extensive covering the last 2 screw areas. In each case, an osteotome was used to remove the bone without difficulty. Having done this and fully exposing the plate, the 3 screws were then removed with a small fragment screwdriver and the plate was then readily removed. The wound was irrigated out well and then closed in layers in the usual fashion using 2-0 Vicryl for wound layers except the skin. A plastic closure was then performed of the skin incision. .

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    Quote Originally Posted by coders_rock! View Post
    Can someone please help me code this report?


    The keloid was first removed with the appropriate skin incision to do so. The skin incision was then taken down through subcutaneous tissue with bleeders clamped and bovied in the usual manner. Identifying the greater trochanter over it and about 4 cm beyond it, the tensor fascia lata was opened and then the vastus lateralis was split longitudinally to expose the plate from its most proximal end to the distal end. On the right side, there was a small degree of bone overlapping it, which was removed with an osteotome on the left. It was more extensive covering the last 2 screw areas. In each case, an osteotome was used to remove the bone without difficulty. Having done this and fully exposing the plate, the 3 screws were then removed with a small fragment screwdriver and the plate was then readily removed. The wound was irrigated out well and then closed in layers in the usual fashion using 2-0 Vicryl for wound layers except the skin. A plastic closure was then performed of the skin incision. .
    answered above..

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