# code for incisional bx r maxillary mass



## jthweatt (Apr 22, 2010)

I need help with a CPT for the following procedure:

OPERATIVE REPORT
PATIENT XXX with right maxillary mass just under the right lip along the posterior aspect of the alveolar ridge.  XXX. . . agreed for a sublabial incision with Caldwell biopsy of this area.

The patient was brought to the operating room and placed supine on the operating table.  She was placed under general anesthesia without difficulty.  The patient was prepped and draped in the usual fashion.  Injection of 1% Lidocaine with 1:100,000 Epinephrine was performed on the gingival sulcus on the right.  A sublabial incision was performed and a freer was used to elevate around the area of question.  This area was soft issue and was around the bone.  Several bites of this were taken using the true cutting sinus forceps.  Essentially, it looked to be a small are of purulent material.  Several more biopsies were taken and the procedure was terminated.  Wound was irrigated.  Bipolar was used to coagulate any bleeders.  The wound was closed with a running 4-o chromic.  . . . 

PATH REPORT
Fibrous connective tissue with extensive acute and chronic inflammation and granulation tissue proliferation consistent with abscess wall.  Negative for fungus.

THANK YOU FOR ANY INPUT OR DIRECTION.  If I am missing something obvious, please let me know that, too.

Jerri, CPC


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