codedog
True Blue
Hello, a few times I come across on path report stating dx as -skin-chronic inflammation, foreign body giant cell reaction, and scar . How would you code this if doctor is excising a back mass ?It seems to me to code this as integumentary but not sure on dx ?or even size , in path it stated a yellowish subcutaneous tissue of 3.5X 1.61x 1.1 cm,any ideas how to code this
PREOPERATIVE DIAGNOSIS: Right upper back mass.
POSTOPERATIVE DIAGNOSIS: Right upper back mass.
PROCEDURE PERFORMED: Excisional biopsy of right upper back mass.
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: e recently seen in my office with what appears to be a recurrent infected epidermal inclusion cyst on her right upper back. The area was incised and drained. Infection was resolved. She has consented for excision.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in left lateral decubitus position. Right upper back was prepped and draped in a sterile fashion. 10 cc of 1% lidocaine with epinephrine were injected for local anesthesia. A longitudinal elliptical incision was made over the mass. Electrocautery was used to dissect through the subcutaneous tissue to excise the mass with grossly negative margins. There was no sign of infection or purulence. The area was completely resected. Hemostasis was achieved with electrocautery. The wound was first irrigated with Betadine and then with normal saline. Wound was inspected and found to be hemostatic. Subcutaneous tissues were closed with interrupted 3-0 Vicryl sutures and 3-0 nylon horizontal mattress and simple sutures were used to close the skin. The skin closed easily without tension. A sterile dressing was applied. The patient tolerated the procedure well.
PREOPERATIVE DIAGNOSIS: Right upper back mass.
POSTOPERATIVE DIAGNOSIS: Right upper back mass.
PROCEDURE PERFORMED: Excisional biopsy of right upper back mass.
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: e recently seen in my office with what appears to be a recurrent infected epidermal inclusion cyst on her right upper back. The area was incised and drained. Infection was resolved. She has consented for excision.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating room table in left lateral decubitus position. Right upper back was prepped and draped in a sterile fashion. 10 cc of 1% lidocaine with epinephrine were injected for local anesthesia. A longitudinal elliptical incision was made over the mass. Electrocautery was used to dissect through the subcutaneous tissue to excise the mass with grossly negative margins. There was no sign of infection or purulence. The area was completely resected. Hemostasis was achieved with electrocautery. The wound was first irrigated with Betadine and then with normal saline. Wound was inspected and found to be hemostatic. Subcutaneous tissues were closed with interrupted 3-0 Vicryl sutures and 3-0 nylon horizontal mattress and simple sutures were used to close the skin. The skin closed easily without tension. A sterile dressing was applied. The patient tolerated the procedure well.