Procedure(s): Right hip bursectomy with possible stitch abscess removal
Dx: Hip pain
In the lateral decubitus position, the patient's prior incision was used, where the skin was incised down to the level of the subcutaneous tissue. In the subcutaneous tissue, there were multiple nodules that were visualized and palpated adherent to the bursa. A complete removal of the nodules, which were a whitish color in nature above the bursa, were provided. This was removed and sent for pathology. The wound was copiously irrigated, followed by closure of the subcutaneous tissue and the skin in layers.
I'm not sure how to code this op note. Should this be coded as a bursectomy or a lesion excision? The nodules were adherent to the bursa so does this make it a bursectomy? The labs came back negative and nothing was sent to pathology.
Thanks in advance.
Dx: Hip pain
In the lateral decubitus position, the patient's prior incision was used, where the skin was incised down to the level of the subcutaneous tissue. In the subcutaneous tissue, there were multiple nodules that were visualized and palpated adherent to the bursa. A complete removal of the nodules, which were a whitish color in nature above the bursa, were provided. This was removed and sent for pathology. The wound was copiously irrigated, followed by closure of the subcutaneous tissue and the skin in layers.
I'm not sure how to code this op note. Should this be coded as a bursectomy or a lesion excision? The nodules were adherent to the bursa so does this make it a bursectomy? The labs came back negative and nothing was sent to pathology.
Thanks in advance.