cclarson
Guru
Hello Everyone, I'm not sure how to code the Dx for this procedure. The doctor removed a suture segment and fibroma from the pt's ankle. Now I know for the fibroma, it would be D21.21. However, I'm not sure how to code the suture segment. Would it be M79.5 for residual foreign body of the soft tissue with a Z code? Or something else? Any advice would be greatly appreciated. Thank you!
POSTOPERATIVE DIAGNOSIS:
Right ankle foreign body.
OPERATION PERFORMED:
Excision of right ankle foreign body and fibroma.
INDICATIONS FOR PROCEDURE:
The patient is a 76-year-old female with a history of prior right ankle surgery with development of an abscess and a foreign body along the medial side of the right ankle.
DESCRIPTION OF PROCEDURE:
The patient had the right lower extremity marked. Appropriate consent was obtained. She was transported to the operating room and placed in the supine position on the operating table, sedated and intubated per anesthesia. The patient had the right lower extremity prepped and draped in a sterile fashion. Time out was taken. Proper identify, extremity, and procedure were confirmed. The tourniquet was inflated to 300 mmHg. A piece of suture material was visible on the medial side of the right ankle. An elliptical incision was created around the suture segment. This was carried through the skin and subcutaneous layers down. A palpable fibroma was identified within the soft tissues on the medial ankle. This was sharply excised, and the suture remnant was removed with the fibroma. Once this was fully excised from the soft tissues, no further abnormal tissue was identified. The incision site was thoroughly irrigated with sterile saline. The skin was closed with subcutaneous 3-0 Monocryl suture and a 3-0 nylon suture in the skin. Local anesthetic was applied around the incision with 0.5% Marcaine plain. The incision site was covered with Xeroform dressing and a sterile dressing.
POSTOPERATIVE DIAGNOSIS:
Right ankle foreign body.
OPERATION PERFORMED:
Excision of right ankle foreign body and fibroma.
INDICATIONS FOR PROCEDURE:
The patient is a 76-year-old female with a history of prior right ankle surgery with development of an abscess and a foreign body along the medial side of the right ankle.
DESCRIPTION OF PROCEDURE:
The patient had the right lower extremity marked. Appropriate consent was obtained. She was transported to the operating room and placed in the supine position on the operating table, sedated and intubated per anesthesia. The patient had the right lower extremity prepped and draped in a sterile fashion. Time out was taken. Proper identify, extremity, and procedure were confirmed. The tourniquet was inflated to 300 mmHg. A piece of suture material was visible on the medial side of the right ankle. An elliptical incision was created around the suture segment. This was carried through the skin and subcutaneous layers down. A palpable fibroma was identified within the soft tissues on the medial ankle. This was sharply excised, and the suture remnant was removed with the fibroma. Once this was fully excised from the soft tissues, no further abnormal tissue was identified. The incision site was thoroughly irrigated with sterile saline. The skin was closed with subcutaneous 3-0 Monocryl suture and a 3-0 nylon suture in the skin. Local anesthetic was applied around the incision with 0.5% Marcaine plain. The incision site was covered with Xeroform dressing and a sterile dressing.
