Hi, I need some assistance with coding this op report. I'm thinking the correct CPT code would be 21014 but want to make sure I'm thinking correctly. Please give me some advice on this:
PROCEDURE: Submandibular incision approach to left maxillary mass.
INDICATIONS FOR PROCEDURE: The patient with a mass entering from the left nasal floor. The patient underwent a CT scan of the sinuses revealing a maxillary mass not involving any dental roots but protruding into the nasal floor and into the anterior portion of the maxilla. It did not appear to penetrate the sinus. The patient presents for surgical correction.
FINDINGS: Cystic mass filling the left anterior maxilla just superior to teeth number 22, 23, and 24. The second branch of the fifth cranial nerve was identified and was protected.
OPERATIVE NOTE: After informed consent was obtained, the patient was taken to the Operating Room where she underwent general endotracheal anesthesia and 1% lidocaine with epinephrine was injected into the left sublabial area. The patient was cleaned, prepped and draped in the usual manner. Timeout was performed. A 15-blade was used to make a sublabial incision, approximately 2 cm in length, extending from the midline to the left superior canine. Soft tissue was incised down to a cystic mass which was identified and was circumferentially dissected with meticulous hemostasis using bipolar cautery. The entire mass was removed. It did protrude into the left nasal floor. Upon removal, there was a defect of the left nasal floor mucosa. After removal, the specimen was sent for permanent pathology. The wound was then closed, approximating the deep sublabial incision with an interrupted 3-0 Vicryl and the mucosal incision was closed with a running locked 4-0 Vicryl. The left nasal floor was also approximated with interrupted 4-0 Vicryl in an interrupted fashion. The patient was then transferred back to care of Anesthesia where she was awakened in the Operating Room and transferred to the Recovery Room in stable condition. All counts were correct.
Thanks so much for your help!!
Vicki
PROCEDURE: Submandibular incision approach to left maxillary mass.
INDICATIONS FOR PROCEDURE: The patient with a mass entering from the left nasal floor. The patient underwent a CT scan of the sinuses revealing a maxillary mass not involving any dental roots but protruding into the nasal floor and into the anterior portion of the maxilla. It did not appear to penetrate the sinus. The patient presents for surgical correction.
FINDINGS: Cystic mass filling the left anterior maxilla just superior to teeth number 22, 23, and 24. The second branch of the fifth cranial nerve was identified and was protected.
OPERATIVE NOTE: After informed consent was obtained, the patient was taken to the Operating Room where she underwent general endotracheal anesthesia and 1% lidocaine with epinephrine was injected into the left sublabial area. The patient was cleaned, prepped and draped in the usual manner. Timeout was performed. A 15-blade was used to make a sublabial incision, approximately 2 cm in length, extending from the midline to the left superior canine. Soft tissue was incised down to a cystic mass which was identified and was circumferentially dissected with meticulous hemostasis using bipolar cautery. The entire mass was removed. It did protrude into the left nasal floor. Upon removal, there was a defect of the left nasal floor mucosa. After removal, the specimen was sent for permanent pathology. The wound was then closed, approximating the deep sublabial incision with an interrupted 3-0 Vicryl and the mucosal incision was closed with a running locked 4-0 Vicryl. The left nasal floor was also approximated with interrupted 4-0 Vicryl in an interrupted fashion. The patient was then transferred back to care of Anesthesia where she was awakened in the Operating Room and transferred to the Recovery Room in stable condition. All counts were correct.
Thanks so much for your help!!
Vicki
