How would you code for rheumatoid nodules being excised? I am confused on this one.
Can anyone help?
POSTOPERATIVE DIAGNOSIS: Right hand rheumatoid cysts regarding the second, third, and fourth digits.
PROCEDURE: Right hand rheumatoid cyst removal from the second, third, and fourth digits.
OPERATIVE PROCEDURE: The patient was brought to the operating room under general anesthesia. The patient was placed in the dorsal decubitus position. Betadine scrubbing and sterile draping was performed. The tourniquet was applied at 250 mmHg.
The patient had severe rheumatoid arthritis with very enlarged hard cysts present on the digits. The nodular were located on the index finger at the pulp, the second digit regarding the ulnar border volar aspect of the second phalanx, and the fourth digit at the same area as well as on the dorsal aspect directly regarding the PIP joint.
Under loupe magnification, careful dissection was taken down revealing the nodules. All had the same rubbery hard yellow-tan tissue. The tissue was submitted to pathology. The tourniquet was shut down and hemostasis was good. The excision sites were irrigated thoroughly with fluid. The skin was closed with Prolene 4-0 sutures. Digital blocks were done for postoperative pain management. A large dressing was applied. The patient was returned to the recovery room in stable condition.
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