Hi, how would you code this? Thanks!!
POSTOPERATIVE DIAGNOSES: 1. Scrotal lesion suspicious for squamous cell
carcinoma.
2. History of squamous cell carcinoma of the
penis.
3. Neurogenic bladder with urinary
incontinence managed with chronic condom
catheter.
PROCEDURE PERFORMED: Excision of 4 cm ulcerative penoscrotal lesion.
FINDINGS: He had an ulcerative penoscrotal lesion which was circumferential and approximately 4 cm
in diameter in the midline of the penoscrotal junction. Shaft of this penis was erythematous in areas
consistent with his chronic inflammation from his condom catheter. There was no obvious area of
recurrence along the shaft where the glans.
DETAILS OF PROCEDURE: The patient was taken to the operating room and positively identified as
well as the site of surgery during a time-out. After adequate general anesthesia, he was prepped and
draped in the usual sterile fashion in the supine position for excision of scrotal lesion. The shaft of his
penis and glans were carefully inspected. He had areas of erythema and superficial ulceration consistent
with his chronic inflammatory changes adhesive from his condom catheter. The glans was somewhat
indurated. This had been biopsied on couple of prior occasions, which was negative, but did not look
different than it had in the past. Therefore the glands in the shaft areas were not biopsied.
He had approximately 4 cm diameter circumferential ulcerative lesion with varicose changes in the base
located at the midline penoscrotal junction. An elliptical incision was created around the lesion with 15
blade scalpel knife and then using a sharp and blunt dissection, the lesion was dissected off underlying
tissue. This was done without compromising the urethra or corporal bodies. Hemostasis was obtained
with electrocautery. The deep interrupted 3-0 chromic figure-of-eight was placed to reapproximate the
dartos muscle to the base of the penis. This reapproximated the skin edges in a tension free manner. The
skin was then closed with interrupted figure-of-eight 4-0 chromic sutures. This gave excellent
reapproximation of the skin and hemostasis. Antibiotic ointment was placed on the incision. A fluff
dressing was held in place with a scrotal support. A 16-French Foley Catheter was placed at the end of
the procedure and placed to gravity drainage. Catheter was irrigated freely and effluent came back clear.
He tolerated the procedure well without complications. All counts were correct. JW 20220217
POSTOPERATIVE DIAGNOSES: 1. Scrotal lesion suspicious for squamous cell
carcinoma.
2. History of squamous cell carcinoma of the
penis.
3. Neurogenic bladder with urinary
incontinence managed with chronic condom
catheter.
PROCEDURE PERFORMED: Excision of 4 cm ulcerative penoscrotal lesion.
FINDINGS: He had an ulcerative penoscrotal lesion which was circumferential and approximately 4 cm
in diameter in the midline of the penoscrotal junction. Shaft of this penis was erythematous in areas
consistent with his chronic inflammation from his condom catheter. There was no obvious area of
recurrence along the shaft where the glans.
DETAILS OF PROCEDURE: The patient was taken to the operating room and positively identified as
well as the site of surgery during a time-out. After adequate general anesthesia, he was prepped and
draped in the usual sterile fashion in the supine position for excision of scrotal lesion. The shaft of his
penis and glans were carefully inspected. He had areas of erythema and superficial ulceration consistent
with his chronic inflammatory changes adhesive from his condom catheter. The glans was somewhat
indurated. This had been biopsied on couple of prior occasions, which was negative, but did not look
different than it had in the past. Therefore the glands in the shaft areas were not biopsied.
He had approximately 4 cm diameter circumferential ulcerative lesion with varicose changes in the base
located at the midline penoscrotal junction. An elliptical incision was created around the lesion with 15
blade scalpel knife and then using a sharp and blunt dissection, the lesion was dissected off underlying
tissue. This was done without compromising the urethra or corporal bodies. Hemostasis was obtained
with electrocautery. The deep interrupted 3-0 chromic figure-of-eight was placed to reapproximate the
dartos muscle to the base of the penis. This reapproximated the skin edges in a tension free manner. The
skin was then closed with interrupted figure-of-eight 4-0 chromic sutures. This gave excellent
reapproximation of the skin and hemostasis. Antibiotic ointment was placed on the incision. A fluff
dressing was held in place with a scrotal support. A 16-French Foley Catheter was placed at the end of
the procedure and placed to gravity drainage. Catheter was irrigated freely and effluent came back clear.
He tolerated the procedure well without complications. All counts were correct. JW 20220217