CassyWelzen
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Below is part of the surgeons op note for a soft tissue mass excision. The surgeon is stating there was a "void" left from the mass excision that required a skin flap from the medial left foot to cover. Would 14040 be acceptable? Also, what diagnosis codes would be appropriate. I have several in my coding companion for Podiatry but not sure they apply as they are injury codes.
"Surgery began in the following manner:
Attention was directed to the left foot where a palpable mass was noted sub 1st met head. A circumferential incision was then made directly over the mass. The incision was deepened using both sharp and blunt dissection with care taken to avoid all vital neurovascular structures. The mass was carefully dissected free from all surrounding tissues and was then removed in toto. The mass was sent to pathology for further evaluation via fresh frozen section. The mass was approximately 4.5 cm x 3.5 cm. The remaining subcutaneous tissues were then explored and noted to be normal in appearance. The incision was then deepened with blunt dissection, and it was noted that there were no signs of stalking of the mass, abscess formation, or active drainage from the site.
The wounds were then flushed with copious amounts of normal saline solution. The void left by the soft tissue mass excision required a skin flap from the medial left foot to cover. The skin flap was retained with its vascularity and was full thickness, rotted over the void."
Thanks,
Cassy
"Surgery began in the following manner:
Attention was directed to the left foot where a palpable mass was noted sub 1st met head. A circumferential incision was then made directly over the mass. The incision was deepened using both sharp and blunt dissection with care taken to avoid all vital neurovascular structures. The mass was carefully dissected free from all surrounding tissues and was then removed in toto. The mass was sent to pathology for further evaluation via fresh frozen section. The mass was approximately 4.5 cm x 3.5 cm. The remaining subcutaneous tissues were then explored and noted to be normal in appearance. The incision was then deepened with blunt dissection, and it was noted that there were no signs of stalking of the mass, abscess formation, or active drainage from the site.
The wounds were then flushed with copious amounts of normal saline solution. The void left by the soft tissue mass excision required a skin flap from the medial left foot to cover. The skin flap was retained with its vascularity and was full thickness, rotted over the void."
Thanks,
Cassy