britbrit852003
Guru
Two coders in my office are coding the following cyst removal differently I need opnions on how others would code this.
Per the provider the cyst size was 3.0cm x 2.0cm but he only did an incision of 1.5 cm for cosmetic reasons. So the lesion and the incision were two different sizes. Any help is grealty appreciated on this issue.
Procedure Note
Exam-
Skin:
3cm x 2cm x 1cm cyst mid back at midline. no evidence of infection
Cyst Removal Note:
The patient complains of pain, tenderness, and swelling.
Size (in cm): 3.0 x 2.0
Comment: cyst removal mid central back: reviewed risks/benefits, consent signed. pt placed in prone position, cyst cleaned with betadyne x 3 and alcohol swabs x 3. area anesthesized with 2mL 1% lidocaine with epinepherine using 30 ga 1" needle. after confirming adequate anesthesia, #11 blade scapel used to make 1.5cm linear incision made center of cyst. using forcep and tissue scissors cyst excised/teased out relatively intact. cavity explored and any further tissue removed without difficulty. area closed with 3 4-0 simple interupted sutures with good wound approximation. no complications, pt tolerated well
Additional Instructions: pt to notify office of any problems/concerns assoc with cyst removal site or sutures. return suture removal 10 days
Per the provider the cyst size was 3.0cm x 2.0cm but he only did an incision of 1.5 cm for cosmetic reasons. So the lesion and the incision were two different sizes. Any help is grealty appreciated on this issue.
Procedure Note
Exam-
Skin:
3cm x 2cm x 1cm cyst mid back at midline. no evidence of infection
Cyst Removal Note:
The patient complains of pain, tenderness, and swelling.
Size (in cm): 3.0 x 2.0
Comment: cyst removal mid central back: reviewed risks/benefits, consent signed. pt placed in prone position, cyst cleaned with betadyne x 3 and alcohol swabs x 3. area anesthesized with 2mL 1% lidocaine with epinepherine using 30 ga 1" needle. after confirming adequate anesthesia, #11 blade scapel used to make 1.5cm linear incision made center of cyst. using forcep and tissue scissors cyst excised/teased out relatively intact. cavity explored and any further tissue removed without difficulty. area closed with 3 4-0 simple interupted sutures with good wound approximation. no complications, pt tolerated well
Additional Instructions: pt to notify office of any problems/concerns assoc with cyst removal site or sutures. return suture removal 10 days