KNP40806
Networker
I have no experience with plastic surgery. Can someone help with the coding of the following op report. Any info will help
PREOPERATIVE DIAGNOSIS: Acquired soft tissue scar in face.
POSTOPERATIVE DIAGNOSIS: Acquired soft tissue scar in face.
PROCEDURE: Excision with layered closure of 15 to 18 cm of scars on her left chin, left mandibular area, and the right medial cheek.
SURGEON:
FINDINGS: Areas undermined gently, closed subcutaneous tissue and injected with about 10 mg of Kenalog.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
COUNTS: Correct.
BRIEF HISTORY: The patient is a very pleasant 14-year-old who really was devastated with some scarring sustained from a dog bite incident approximately five years ago. She is now taken for revision of very wide scars that apparently are hypertrophied as well as correction of her vermilion border of her lower lip.
DESCRIPTION OF PROCEDURE: The patient was placed supine. Anesthesia was induced without difficulty. She was then prepped and draped sterilely. The scars, which are listed above, were injected using a total of 6 mL of 1% lidocaine with epinephrine. The scars then were completely excised out and the edges undermined sharply approximately 0.5 cm in all directions and then after hemostasis had been obtained, the wounds were closed in layers with deep as well as a running subcutaneous tissue 6-0 Monocryl. The vermilion border of her left lower lip through which the scar extended had to be reapproximated since it was off approximately 2 mm. At the conclusion, her skin edges appeared to be well reapproximated. She was then injected with approximately 10 mL of Kenalog, which was mixed with lidocaine and supported with Steri-Strips. She tolerated this well. She was extubated and taken to the recovery area in stable condition.
PREOPERATIVE DIAGNOSIS: Acquired soft tissue scar in face.
POSTOPERATIVE DIAGNOSIS: Acquired soft tissue scar in face.
PROCEDURE: Excision with layered closure of 15 to 18 cm of scars on her left chin, left mandibular area, and the right medial cheek.
SURGEON:
FINDINGS: Areas undermined gently, closed subcutaneous tissue and injected with about 10 mg of Kenalog.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
COUNTS: Correct.
BRIEF HISTORY: The patient is a very pleasant 14-year-old who really was devastated with some scarring sustained from a dog bite incident approximately five years ago. She is now taken for revision of very wide scars that apparently are hypertrophied as well as correction of her vermilion border of her lower lip.
DESCRIPTION OF PROCEDURE: The patient was placed supine. Anesthesia was induced without difficulty. She was then prepped and draped sterilely. The scars, which are listed above, were injected using a total of 6 mL of 1% lidocaine with epinephrine. The scars then were completely excised out and the edges undermined sharply approximately 0.5 cm in all directions and then after hemostasis had been obtained, the wounds were closed in layers with deep as well as a running subcutaneous tissue 6-0 Monocryl. The vermilion border of her left lower lip through which the scar extended had to be reapproximated since it was off approximately 2 mm. At the conclusion, her skin edges appeared to be well reapproximated. She was then injected with approximately 10 mL of Kenalog, which was mixed with lidocaine and supported with Steri-Strips. She tolerated this well. She was extubated and taken to the recovery area in stable condition.
