I am new to coding for general surgery. Someone please help!
Preprocedure Diagnosis: Multiple tumor masses, causing pain and discomfort on movement. Patient is post discectomy and left radiculopathy surgery in 2008 at same areas, L3-L4-L5. Now with right pain, dissimilar to the radiculopathy of the right side. The pain is different
Post Procedure Diagnosis: Excisional biopsy of lipomas (multiple tumors), lower back, on right side of L3-L4-L5.
Anesthesia: General with Demerol, Fentanyl and rocuronium IV
The patient was prepped and draped in the usual fashion, using a Betadine prep. The patient was intubated and placed in a prone position. The patient was prepped and marked, designating on the right side of the vertebral bodies, of L3-L4-L5 area, the masses present. The patient had previously been examined and affirmed that they be in that location. The area was then marked carefully and the incision was then marked carefully with hashmarks with marking pencil. The incision was then carried from the upper L3 level along the lines of Langerhans, to a distance of 4.5 cm. The incision was carried down to the subcutaneous fat to the thoracodorsal fascia and lumbar thoracic fascia. The fascia was then incised and there, protruding up from the depth of the incision, above the erectus spinale muscle, were 3 areas of lipomatous tissue. These were inspected individually, by sharp and blunt dissection, surrounding the area, clamping with Halstead clamp at the base of the lipoma, where the blood vessel enters, amputation above the Halstead clamp and tying with 2-0 Vicryl on a CT1 needle, in a suture ligature fashion, Clamps were loosened as they were tied. The same procedure was done for the other 2 areas, the L3 area. The total mass of the area at L5 according to the pathology report was 5cm x 4cmx 1.5 cm weighing 12.5 grams. Similar areas of lipoma were resected to L3 level. Skin was incised, about 4 cm and carried down to the subcutaneous encountered. These yellowish fatty tissues appeared to be encapsulated. A total of 3 areas were removed measuring 3.5x 3.5x2cm. Another area labled nerve at the base of the lipomas was excised along with the lipoma. This measured 3 cm in length and 0.2 acoss.A white tannish core structure resembling a nerve was labeled and confirmed by pathology as nerve. The incisions were then closed making sure all bleeding was controlled by hemostat and suture ligature application. The area was irrigated with normal saline. There was no bleeding. Incision was closed. The thoracolumbar fasia was closed with 2-0 Vicryl suture in interrupted manner. Both incisions in the skin was closed with subcuticular suture of 3-0 Vicryl on the subdermal area in running interlocking suture. The sking was closed with 5-0 Monocryl in a subcuticilar zig zag fashion thus requiring no skin sutures. The Monocryl will resolve in time. No bleeding was encountered. The patient tolerated the procedure well. Specimens were sent to the pathology for confirmation of benign lipomas, section of nerve. Hopefully this section of nerve was involved with her pain of uncertain L-4 dermatome. The wound was then dressed with antibiotic solution and Furacin gauze and ABD gauze and then sent to the recovery room in satisfactory condition.
I really would appriciate the help
Are you coding for the physician or the hospital?
Originally Posted by mcollins007
I am coding for the physician.
Excision of lipoma
Exicision of lipoma is found in the musculoskeletal section of CPT. In this case look at 21930-21933 to find the code(s) that fit your operative report.
Hope that helps.
F Tessa Bartels, CPC, CEMC