codedog
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If doctor stated he went down through subcutaneous tissue and it was a lipoma , , does that mean code it to musculoskeletal system.I am pretty sure you can. The reason why I ask is because we have the same doctor office doing the booking as integumentary codes-11400-11446-, but when I get operative report in I tend to want to go it in musculosketal system. DOC office says not to change it because they had authorization only for the integumentary code, and coding anything else we may or may not get paid for it. I work in a ASC and they do get authorization also ,only what was on the booking ,so any sudggestions would be helpful, I may be wrong also, just let me know. thanks -here is an example
PREOPERATIVE DIAGNOSIS: Right flank mass.
POSTOPERATIVE DIAGNOSIS: Right flank mass.
PROCEDURE PERFORMED: Excision of right flank mass.
ANESTHESIA:
ANESTHESIOLOGIST:
PROCEDURE IN DETAIL: After adequate premedication, the patient was taken to the operating room and placed on the operating room table in a supine position and then turned with the right flank up. The right flank was prepped and draped in a sterile fashion. Using approximately 10 cc of 0.5% Xylocaine with epinephrine, local anesthesia was obtained. An elliptical incision was made encompassing the skin and subcutaneous tissue and mass, and deepened down through the subcutaneous tissue. Once the entire mass had been surrounded, this was removed. Bleeding was controlled with electrocautery. The wound was then closed with 3-0 Vicryl in the deep tissues and subcuticular nylon in the skin. Blood loss was minimal. The patient tolerated the procedure well and was taken to the recovery in stable condition.
X____________________
PREOPERATIVE DIAGNOSIS: Right flank mass.
POSTOPERATIVE DIAGNOSIS: Right flank mass.
PROCEDURE PERFORMED: Excision of right flank mass.
ANESTHESIA:
ANESTHESIOLOGIST:
PROCEDURE IN DETAIL: After adequate premedication, the patient was taken to the operating room and placed on the operating room table in a supine position and then turned with the right flank up. The right flank was prepped and draped in a sterile fashion. Using approximately 10 cc of 0.5% Xylocaine with epinephrine, local anesthesia was obtained. An elliptical incision was made encompassing the skin and subcutaneous tissue and mass, and deepened down through the subcutaneous tissue. Once the entire mass had been surrounded, this was removed. Bleeding was controlled with electrocautery. The wound was then closed with 3-0 Vicryl in the deep tissues and subcuticular nylon in the skin. Blood loss was minimal. The patient tolerated the procedure well and was taken to the recovery in stable condition.
X____________________
