codedog
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Patient had a lesion removed but path report came back as a hemangioma but according to the cpt code dx dont match up to the cpt,so do Ijust code this as a benign lesion ?
PREOPERATIVE DIAGNOSES: Left thigh lesion.
POSTOPERATIVE DIAGNOSES: Left thigh lesion.
PROCEDURES PERFORMED: Excision of left thigh lesion.
ANESTHESIA: Local with 1% lidocaine. Antibiotic prophylaxis Ancef.
SPECIMENS: left thigh lesion marked with short stitch superior along lateral and was passed off the field.
COMPLICATIONS: None.
INDICATIONS: complains of a lesion in the left anterior thigh for the past few months, which sometimes increases in size and then regresses; however, it is recurrent for which he requires surgical excision.
BRIEF OPERATIVE NOTE: The risks of the surgery including bleeding, infection, scar, damage to the nearby structures including vessels, nerves, inability to fully remove, and need for additional surgery were explained to the patient in detail, who understood the procedure well and gave us his permission.
After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating table. The left thigh area was prepped and draped in standard surgical fashion. 1% lidocaine was used to provide local anesthesia. On examination, this lesion was approximately 1 cm in size. An elliptical incision was made and carried out to the deeper tissues. The lesion was resected from the surrounding structures using Bovie electrocautery and was retrieved and was marked with a silk stitch and then passed off the field as a specimen. The area was then irrigated. Flaps were created to prevent tension on the closure. Following this, the subcutaneous tissue was closed using #3-0 Vicryl interrupted stitches followed by closure of the skin with #2-0 nylon interrupted stitches. The wound was cleaned and dried and Steri-Strips were applied.
The sponge, needle, and instrument counts were correct x3 at the end of the case.
The patient tolerated the procedure well and was transported to the recovery room in a stable condition.
PREOPERATIVE DIAGNOSES: Left thigh lesion.
POSTOPERATIVE DIAGNOSES: Left thigh lesion.
PROCEDURES PERFORMED: Excision of left thigh lesion.
ANESTHESIA: Local with 1% lidocaine. Antibiotic prophylaxis Ancef.
SPECIMENS: left thigh lesion marked with short stitch superior along lateral and was passed off the field.
COMPLICATIONS: None.
INDICATIONS: complains of a lesion in the left anterior thigh for the past few months, which sometimes increases in size and then regresses; however, it is recurrent for which he requires surgical excision.
BRIEF OPERATIVE NOTE: The risks of the surgery including bleeding, infection, scar, damage to the nearby structures including vessels, nerves, inability to fully remove, and need for additional surgery were explained to the patient in detail, who understood the procedure well and gave us his permission.
After informed consent was obtained, the patient was taken to the operating room and placed supine on the operating table. The left thigh area was prepped and draped in standard surgical fashion. 1% lidocaine was used to provide local anesthesia. On examination, this lesion was approximately 1 cm in size. An elliptical incision was made and carried out to the deeper tissues. The lesion was resected from the surrounding structures using Bovie electrocautery and was retrieved and was marked with a silk stitch and then passed off the field as a specimen. The area was then irrigated. Flaps were created to prevent tension on the closure. Following this, the subcutaneous tissue was closed using #3-0 Vicryl interrupted stitches followed by closure of the skin with #2-0 nylon interrupted stitches. The wound was cleaned and dried and Steri-Strips were applied.
The sponge, needle, and instrument counts were correct x3 at the end of the case.
The patient tolerated the procedure well and was transported to the recovery room in a stable condition.