The patient was brought to the operating room, where after identification of the patient and planned , general anesthesia was induced and the right lateral thigh was prepped and draped in sterile fashion longitudinal incision was made over the previously marked area and carried down through superficial fat to the investing fascia of the thigh. Somewhat thin and attenuated but not otherwise abnormal. As it was opened the muscles of the lateral aspect of the anterior thigh are exposed but there is no evidence of any tumor mass, lipoma, or other soft tissue abnormality in the area there extensive dissection is carried deeply into the thigh all the way to to the level of the femur and no abnormal masses identified, only normal appearing muscle in the area. Several repeated evaluations of this area failed to reveal any evidence of tumor, so by way of explanation, the mass apparently is formed by either a torn tendon of the vastus lateralis muscle, or herniation of the muscle through the deep fascia. The latter possibility in mind, both edges of the fascia were mobilized and closed with mattress sutures of heavy Vicryl. Subcutaneous tissue and skin are then closed with fine absorbable suture and a sterile pressure dressing was applied. No attempt was made to resect any of the prominent muscle, because it all looks quite normal and further evaluation is probably necessary before any extensive resection is undertaken. The patient was then awaken from anesthetic having tolerated the procedure well. Estimated blood loss was minimal and there no intraoperative complications. She was sent to recovery room in satisfactory condition.
How do you code an excision of a mass without a mass?? there isn't any pathology either.
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How do you code an excision of a mass without a mass?? there isn't any pathology either.
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