vmounce
Guru
I coded the op note below as LT 28060 728.71 and LT 28041 728.2. But I am not sure on the second codes. Can someone look
Over the operative report below? Path came back as Nodular Fascitis, and benign fibromuscular fatty tissue with minimal fibrosis.
I appreciate any information.
Vickie Mounce
PREOPERATIVE DIAGNOSES:
Plantar fibromatosis x 2, left foot.
Questionable ganglionic lesion.
POSTOPERATIVE DIAGNOSES:
Plantar fibromatosis x 2, left foot.
Questionable ganglionic lesion.
PROCEDURE: Excision of plantar fibromatosis nodules x 2 and questionable ganglionic lesion, left foot.
INDICATION: Conservative care has failed to alleviate the patient's painful left foot deformity.
OPERATIVE PROCEDURE: The procedure was explained in detail. The risks and complications were explained in detail. No guarantees were given. The patient was taken to the OR and placed in the supine position premedicated by the Department of Anesthesia using IV sedation. The left foot was prepped and draped in the normal sterile fashion. Using 1% lidocaine, the plantar fascial band was anesthetized both distally at the first MPJ level and at the mid plantar fascial band level.
A small curvilinear incision was made on the plantar aspect of the foot overlying the first MPJ. The skin incision was deepened down through the superficial and deep fascia. A small plantar fibromatosis nodule was identified, excised, and submitted to pathology. It is questionable whether this lesion at the first MPJ is a plantar fibromatosis or a ganglionic type of lesion.
A larger incision was made at the mid plantar fascial band. The skin incision was deepened down through the superficial and deep fascia. A larger plantar fibromatosis nodule measuring approximately 0.5 cm was removed in toto with surrounding plantar fascial tissue. This was submitted to pathology. Both wounds were flushed and closed with 3-0 Prolene sutures.
Betadine and sterile dressings were applied. The tourniquet was deflated and neurovascular status returned to preoperative levels. Care had been taken to avoid all neurovascular structures during the procedure. The patient tolerated the procedure and anesthesia well without complication. She was instructed on postoperative pain management and postoperative wound care. I will see her back in my office in one week.
Over the operative report below? Path came back as Nodular Fascitis, and benign fibromuscular fatty tissue with minimal fibrosis.
I appreciate any information.
Vickie Mounce
PREOPERATIVE DIAGNOSES:
Plantar fibromatosis x 2, left foot.
Questionable ganglionic lesion.
POSTOPERATIVE DIAGNOSES:
Plantar fibromatosis x 2, left foot.
Questionable ganglionic lesion.
PROCEDURE: Excision of plantar fibromatosis nodules x 2 and questionable ganglionic lesion, left foot.
INDICATION: Conservative care has failed to alleviate the patient's painful left foot deformity.
OPERATIVE PROCEDURE: The procedure was explained in detail. The risks and complications were explained in detail. No guarantees were given. The patient was taken to the OR and placed in the supine position premedicated by the Department of Anesthesia using IV sedation. The left foot was prepped and draped in the normal sterile fashion. Using 1% lidocaine, the plantar fascial band was anesthetized both distally at the first MPJ level and at the mid plantar fascial band level.
A small curvilinear incision was made on the plantar aspect of the foot overlying the first MPJ. The skin incision was deepened down through the superficial and deep fascia. A small plantar fibromatosis nodule was identified, excised, and submitted to pathology. It is questionable whether this lesion at the first MPJ is a plantar fibromatosis or a ganglionic type of lesion.
A larger incision was made at the mid plantar fascial band. The skin incision was deepened down through the superficial and deep fascia. A larger plantar fibromatosis nodule measuring approximately 0.5 cm was removed in toto with surrounding plantar fascial tissue. This was submitted to pathology. Both wounds were flushed and closed with 3-0 Prolene sutures.
Betadine and sterile dressings were applied. The tourniquet was deflated and neurovascular status returned to preoperative levels. Care had been taken to avoid all neurovascular structures during the procedure. The patient tolerated the procedure and anesthesia well without complication. She was instructed on postoperative pain management and postoperative wound care. I will see her back in my office in one week.