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Requesting assistance in determining the CPT and ICD codes for the following surgery. Thank you in advance.
POSTOPERATIVE DIAGNOSES: Bilateral vulvar hemangiomas, perineal redundant tissue, left vulvar skin lesion.
PROCEDURES PERFORMED: Excision of left vulvar skin lesion, fulguration of bilateral vulvar hemangiomas, perineorrhaphy.
FINDINGS: A 2-cm left vulvar pedunculated skin lesion. Bilateral vulvar 13 hemangiomas. Redundant perineal tissue with distortion of the perineum and keratinized tissue hanging from the perineal body.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and after an adequate level of general anesthesia was obtained, she was placed in the dorsal lithotomy position, prepped and draped, and after this lidocaine was injected subcutaneously for postoperative discomfort management. The 13 hemangiomas were removed with the electro excision apparatus, two of which were large enough to submit to Pathology. The rest were fulgurated and on this adequate hemostasis was noted. After this, a 2-cm pedunculated left vulvar skin lesion was removed from its base also using the electro excision and the base was coagulated with adequate hemostasis. After this, the posterior perineum and vagina were evaluated and Allis clamps were placed laterally one on each side through the perineal area. The redundant tissue was noted to be excessive and hanging from this area.
The midline of the posterior perineum was also held with an Allis clamp and the area between all three clamps was incised using a scalpel and the redundant tissue was removed in a triangle over the perineal area. The excess tissue was removed and sent to Pathology and the remaining deficit was closed with #4-0 Monocryl in subcuticular fashion thus reapproximating the skin edges with complete resolution of the hanging excess tissue. The area was noted to be hemostatic and after this the patient was the patient was awakened and taken to the recovery room in stable condition.
POSTOPERATIVE DIAGNOSES: Bilateral vulvar hemangiomas, perineal redundant tissue, left vulvar skin lesion.
PROCEDURES PERFORMED: Excision of left vulvar skin lesion, fulguration of bilateral vulvar hemangiomas, perineorrhaphy.
FINDINGS: A 2-cm left vulvar pedunculated skin lesion. Bilateral vulvar 13 hemangiomas. Redundant perineal tissue with distortion of the perineum and keratinized tissue hanging from the perineal body.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and after an adequate level of general anesthesia was obtained, she was placed in the dorsal lithotomy position, prepped and draped, and after this lidocaine was injected subcutaneously for postoperative discomfort management. The 13 hemangiomas were removed with the electro excision apparatus, two of which were large enough to submit to Pathology. The rest were fulgurated and on this adequate hemostasis was noted. After this, a 2-cm pedunculated left vulvar skin lesion was removed from its base also using the electro excision and the base was coagulated with adequate hemostasis. After this, the posterior perineum and vagina were evaluated and Allis clamps were placed laterally one on each side through the perineal area. The redundant tissue was noted to be excessive and hanging from this area.
The midline of the posterior perineum was also held with an Allis clamp and the area between all three clamps was incised using a scalpel and the redundant tissue was removed in a triangle over the perineal area. The excess tissue was removed and sent to Pathology and the remaining deficit was closed with #4-0 Monocryl in subcuticular fashion thus reapproximating the skin edges with complete resolution of the hanging excess tissue. The area was noted to be hemostatic and after this the patient was the patient was awakened and taken to the recovery room in stable condition.