Case Study:
11420: 3-Step Guideline to Mark Your Lesion Excision Report
Published on Sat Sep 11, 2010
Lesion and margin measurements dictate your reimbursement -- find out why.Sometimes the reports you receive from your physician/surgeon only leaves you confused on what codes to use in your claim. Resolve this dilemma by reading through the documentation with scrutinizing eyes, and you'd be able to determine the appropriate codes and areas for clarification in no time. Examine the following op note:Preoperative diagnosis: Unknown soft tissue mass, left foot Postoperative diagnosis: Unknown soft tissue mass, left footOperation: Excision of subcutaneous soft tissue mass, left foot Gross findings and procedure description:Anesthesia: Local with IV sedationHemostasis: Pneumatic tourniquet at 250 mmHg x 18 minutesEstimated blood loss: Less than 5 mLMaterials: Xeroform gauze and 3-0 ProlenePost-op injections: 5 mL 0.5 percent Marcaine plainProcedure: This patient was taken to the operating room and placed on the operating table in supine position. Following the introduction of intravenous sedation and regional local anesthesia, the left foot [...]