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I'm confused when you use the integementary codes and when you use the musculoskeletal codes for lesion excision? Please help
PREOPERATIVE DIAGNOSIS: Right posterior neck mass consistent with lipoma approximately 1 cm in size with associated neck pain.
POSTOPERATIVE DIAGNOSIS: Right posterior neck mass consistent with lipoma approximately 1 cm in size with associated neck pain.
NAME OF PROCEDURE: Right neck mass excision of lipoma with a small fasciotomy, closure of wound of approximately 2 cm.
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: Fatty tissue to pathology.
ESTIMATED BLOOD LOSS: Less than 5 mL.
FINDINGS: the patient is a pleasant 36 -year-old white female with a history of the above noted diagnosis. Operative findings included a right posterior neck mass that was consistent with lipoma beneath the fascia overtop of the trapezius muscle.
TECHNIQUE: the patient was brought into the operative suite and comfortably positioned on the table. General endotracheal anesthesia was induced. Appropriate drapes were placed Attention was turned to the right neck. The neck was prepped and draped in usual sterile fashion. The area was infiltrated with 2% lidocaine with 1-100,000 epinephrine. Incision was made about 2 cm in length with a sharp knife. Dissection was carried through the subcutaneous fat down to the superficial cervical fascia. This was sharply incised and the lipoma was identified and carefully dissected from the fascia and underlying trapezius muscle. Part of the muscle was excised. The fascia was left open in a fasciotomy type procedure for depression. The base and some little residual fat tissue was cauterized with bipolar cautery. The deep tissue was then closed with 5-0 Vicryl sutures and skin closed with running 5-0 nylon suture.
Sterile dressing was applied. The drapes and instruments were removed. The patient was returned to the care of Anesthesia, allowed to awaken and transported in stable condition to the recovery room having tolerated the procedure well.
PREOPERATIVE DIAGNOSIS: Right posterior neck mass consistent with lipoma approximately 1 cm in size with associated neck pain.
POSTOPERATIVE DIAGNOSIS: Right posterior neck mass consistent with lipoma approximately 1 cm in size with associated neck pain.
NAME OF PROCEDURE: Right neck mass excision of lipoma with a small fasciotomy, closure of wound of approximately 2 cm.
ANESTHESIA: General.
COMPLICATIONS: None.
SPECIMENS: Fatty tissue to pathology.
ESTIMATED BLOOD LOSS: Less than 5 mL.
FINDINGS: the patient is a pleasant 36 -year-old white female with a history of the above noted diagnosis. Operative findings included a right posterior neck mass that was consistent with lipoma beneath the fascia overtop of the trapezius muscle.
TECHNIQUE: the patient was brought into the operative suite and comfortably positioned on the table. General endotracheal anesthesia was induced. Appropriate drapes were placed Attention was turned to the right neck. The neck was prepped and draped in usual sterile fashion. The area was infiltrated with 2% lidocaine with 1-100,000 epinephrine. Incision was made about 2 cm in length with a sharp knife. Dissection was carried through the subcutaneous fat down to the superficial cervical fascia. This was sharply incised and the lipoma was identified and carefully dissected from the fascia and underlying trapezius muscle. Part of the muscle was excised. The fascia was left open in a fasciotomy type procedure for depression. The base and some little residual fat tissue was cauterized with bipolar cautery. The deep tissue was then closed with 5-0 Vicryl sutures and skin closed with running 5-0 nylon suture.
Sterile dressing was applied. The drapes and instruments were removed. The patient was returned to the care of Anesthesia, allowed to awaken and transported in stable condition to the recovery room having tolerated the procedure well.
