codedog
True Blue
this operative is a tough one for me . I want to code 22903 for the lipoma of anterior abdominal wall mass ,and then 11404 for the posterior mass - path report did come back a a lipoma and cyst
22903- 214.9
111404- 706.2
would this be correct /
POSTOPERATIVE DIAGNOSES: Anterior abdominal wall mass, clinically lipoma, greater than 5 cm. Posterior thoracic mass, clinically epidermal inclusion cyst, 3 to 4 cm.
.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table, underwent general anesthesia with successful endotracheal intubation. The area of interest was prepped and draped in normal fashion. Preoperative antibiotics were given prior to skin incision. Time-out had been performed to identify correct patient and correct procedure. Five minutes were waited prior to prepping the area with DuraPrep solution prior to using Bovie cauterization. An incision on the left anterior abdominal wall was made directly over the mass. Incision was around 7 to 8 cm. Dissection was carried down through the skin and subcutaneous tissue. What appeared to be clinically a lipoma of over 5 cm was removed. The entire surrounding tissue and lining was removed with this. It was sent to Pathology for permanent sectioning. Excellent hemostasis was noted to be obtained. The subdermal layers were closed with 3-0 Vicryl interrupted and 3-0 nylon horizontal mattress used to close the skin. After this, the patient was then put in the prone position and posterior thorax was reprepped and redraped. The area of concern had been identified. It was on the left side. It appeared to be an epidermal inclusion cyst. One could see the central pit of it. An incision was made to include that in the middle of it. The entire epidermal inclusion cyst with surrounding fat was shelled out. It was around 3 to 4 cm, sent to Pathology for permanent sectioning. There was noted to be excellent hemostasis. The area was irrigated. The wound was closed with 3-0 nylon in horizontal mattress fashion. Sterile dressing was placed.
The patient tolerated the procedure and was transferred to the recovery room in stable condition.
22903- 214.9
111404- 706.2
would this be correct /
POSTOPERATIVE DIAGNOSES: Anterior abdominal wall mass, clinically lipoma, greater than 5 cm. Posterior thoracic mass, clinically epidermal inclusion cyst, 3 to 4 cm.
.
PROCEDURE IN DETAIL:
After appropriate informed consent was signed, the patient was taken to the operating room, was transferred to the operating table, underwent general anesthesia with successful endotracheal intubation. The area of interest was prepped and draped in normal fashion. Preoperative antibiotics were given prior to skin incision. Time-out had been performed to identify correct patient and correct procedure. Five minutes were waited prior to prepping the area with DuraPrep solution prior to using Bovie cauterization. An incision on the left anterior abdominal wall was made directly over the mass. Incision was around 7 to 8 cm. Dissection was carried down through the skin and subcutaneous tissue. What appeared to be clinically a lipoma of over 5 cm was removed. The entire surrounding tissue and lining was removed with this. It was sent to Pathology for permanent sectioning. Excellent hemostasis was noted to be obtained. The subdermal layers were closed with 3-0 Vicryl interrupted and 3-0 nylon horizontal mattress used to close the skin. After this, the patient was then put in the prone position and posterior thorax was reprepped and redraped. The area of concern had been identified. It was on the left side. It appeared to be an epidermal inclusion cyst. One could see the central pit of it. An incision was made to include that in the middle of it. The entire epidermal inclusion cyst with surrounding fat was shelled out. It was around 3 to 4 cm, sent to Pathology for permanent sectioning. There was noted to be excellent hemostasis. The area was irrigated. The wound was closed with 3-0 nylon in horizontal mattress fashion. Sterile dressing was placed.
The patient tolerated the procedure and was transferred to the recovery room in stable condition.
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