lindacoder
Guest
Not really sure where to go on this one - patient has Medicare so need to watch what CPT and ICD-9 codes I use.
An elliptical incision was made to incorporate both palpable abnormalities. Dissection was then carried down using electrocautery. A superficial vein which was likely the basilic vein in the forearm was identified. This was a feeding into the are of palpable abnormality. With greater than a centimeter margin from the palpable abnormality, the vein was isolated. It was controlled between clamps, transected and ligated with 2-0 Vicryl. In a similar fashion, at the distal aspect of the wound , again the vein appeared normal. This area once again was dissected free. This was controlled between clamps, transected and ligated with Vicryl ties. The lesion was then taken off the fascia of the medial extensor compartment. This lesion was well above the fascia and was not adherent to the underlying fascia at all. Good margins were taken around this. This was then sent to pathology. The wound was palpated and there was found to be no other palpable abnormalities. The deep tissues were then reapproximated with 2-0 Vicryl. Deep dermal tissues were then reapproximated wand the skin was closed with 4-0 moncryl in a running subcuticular fashion. Local anesthetic was infiltrated prior to the closure. Steri-strips and sterile dressing were then applied.
PATHOLOGY; Partically recanalized phlebothrombosis.
Any ideas???
Thanks
An elliptical incision was made to incorporate both palpable abnormalities. Dissection was then carried down using electrocautery. A superficial vein which was likely the basilic vein in the forearm was identified. This was a feeding into the are of palpable abnormality. With greater than a centimeter margin from the palpable abnormality, the vein was isolated. It was controlled between clamps, transected and ligated with 2-0 Vicryl. In a similar fashion, at the distal aspect of the wound , again the vein appeared normal. This area once again was dissected free. This was controlled between clamps, transected and ligated with Vicryl ties. The lesion was then taken off the fascia of the medial extensor compartment. This lesion was well above the fascia and was not adherent to the underlying fascia at all. Good margins were taken around this. This was then sent to pathology. The wound was palpated and there was found to be no other palpable abnormalities. The deep tissues were then reapproximated with 2-0 Vicryl. Deep dermal tissues were then reapproximated wand the skin was closed with 4-0 moncryl in a running subcuticular fashion. Local anesthetic was infiltrated prior to the closure. Steri-strips and sterile dressing were then applied.
PATHOLOGY; Partically recanalized phlebothrombosis.
Any ideas???
Thanks