I'm confused on if I should code this procedure as subcutaneous growths... or lesions... any takers?
Other Complaints: Subcutaneous growths on the forehead and torso
The second issue is concerns over multiple growths. He has had gradually enlarging soft tissue masses involving the right torso and over the forehead. The ones on the torso are painful, if he lays on them and they are very uncomfortable.
Office Procedure:
1) Removal of subcutaneous growths involving the forehead, right torso (x3)
Procedure note: Attention was first turned to the forehead. 1% lidocaine with 1-100,000 epinephrine was injected locally around the lesion. There was an approximately 1.5 cm what appeared to be fatty mass which I was able to dissect free from the surrounding tissue. Hemostasis was maintained with bipolar cautery. The wound was then closed in a layered fashion with 6-0 Vicryl and 5-0 fast absorbing gut. Attention was then turned to the torso lesions. These were removed in a similar fashion, the lesion involving the mid axillary line was quite sizable at approximately 6 cm. The lower right abdomen lesion was approximately 3 cm and the more superior abdominal lesion approximately 4 cm. Hemostasis again was maintained with bipolar cautery. Bactroban cream and Band-Aid dressing was applied to all areas. All 4 lesions were sent in formalin for histologic evaluation. He tolerated this well with scant blood loss.
He had multiple what appear to be lipomas along the forehead and involving the right torso. Given their symptomatic nature and gradual growth we did proceed with excising these today. I will let him know what the pathology demonstrates but I do suspect these are benign growths.
PATH REPORT: Lipomas of the soft tissues of the abdomen, forehead, right back and right side...
Other Complaints: Subcutaneous growths on the forehead and torso
The second issue is concerns over multiple growths. He has had gradually enlarging soft tissue masses involving the right torso and over the forehead. The ones on the torso are painful, if he lays on them and they are very uncomfortable.
Office Procedure:
1) Removal of subcutaneous growths involving the forehead, right torso (x3)
Procedure note: Attention was first turned to the forehead. 1% lidocaine with 1-100,000 epinephrine was injected locally around the lesion. There was an approximately 1.5 cm what appeared to be fatty mass which I was able to dissect free from the surrounding tissue. Hemostasis was maintained with bipolar cautery. The wound was then closed in a layered fashion with 6-0 Vicryl and 5-0 fast absorbing gut. Attention was then turned to the torso lesions. These were removed in a similar fashion, the lesion involving the mid axillary line was quite sizable at approximately 6 cm. The lower right abdomen lesion was approximately 3 cm and the more superior abdominal lesion approximately 4 cm. Hemostasis again was maintained with bipolar cautery. Bactroban cream and Band-Aid dressing was applied to all areas. All 4 lesions were sent in formalin for histologic evaluation. He tolerated this well with scant blood loss.
He had multiple what appear to be lipomas along the forehead and involving the right torso. Given their symptomatic nature and gradual growth we did proceed with excising these today. I will let him know what the pathology demonstrates but I do suspect these are benign growths.
PATH REPORT: Lipomas of the soft tissues of the abdomen, forehead, right back and right side...