# Excision of ankle mass



## Jayashree s (Aug 31, 2018)

Need CPT code for below procedure. Can we code CPT 27632

Preoperative Diagnosis: Left ankle soft tissue mass
Procedure: Excision of ankle soft tissue mass
PROCEDURE IN DETAIL:  The patient was brought into the operating room and placed on the operating room table in the supine position.  The anesthesiologist then proceeded to provide general anesthesia and IV antibiotics.  A tourniquet was placed on the left thigh and the left lower extremity was then scrubbed, prepped and draped in the usual aseptic manner.  Utilizing an Esmarch bandage, the left lower extremity was exsanguinated and the tourniquet was inflated to 300 mmHg.

Attention was then directed toward the distal aspect of the left malleolus where a hard palpable mass of about 3 cm in diameter was appreciated distal to the tibia.  A linear incision was made over this lesion, at which point, cystic fluid was noted.  The incision was deepened around the lesion.  All superficial bleeders were cauterized as necessary and all neurovascular structures were retracted.  Utilizing sharp and blunt dissection, the lesion was excised, and the origin of the cystic fluid was cauterized.  The cystic lesion was then sent off to pathology and the surgical site was then copiously flushed with antibiotic-impregnated  saline solution.

The surgical site was reapproximated utilizing 3-0 Vicryl in a simple interrupted stitch fashion. Lastly, the sldn was reapproximated using 4-0 nylon in a horizontal mattress stitch fashion.  The surgical site was then injected with 10 mL of Marcaine 0.5% plain for postoperative pain relief, and the procedure site was then dressed with Xeroform, 4 x 4 gauze, and Kling.  The patient was placed in a Cam boot for postoperative protection.  The patient tolerated surgery and anesthesia well and was returned to the postanesthesia care unit with all vital signs stable and intact.


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## sxcoder1 (Sep 11, 2018)

I would use that code.


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