codedog
True Blue
how would you code this .soft tissues was noted ,so would axillary be by arm, shoulder , breast < usually axillary says armpit -so does armpitmean forearm -25075? Someone else told me to try 21552 ,
just a note opath report came back as benign breast parenchyma ?
POSTOPERATIVE DIAGNOSIS: Left axillary mass.
PROCEDURE PERFORMED: Excisional biopsy of left axillary mass.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: A 16-year-old female with a left axillary mass, which has not resolved with oral antibiotics.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating table in supine position. The left axilla was prepped and draped in sterile fashion. An elliptical incision was made in the direction of the Langer's lines in the left axilla. Electrocautery was used to dissect through the subcutaneus tissue to excise this soft tissue mass with grossly negative margins. There was no sign of infection. The wound was irrigated with normal saline. It was inspected and found to be hemostatic. Dissection was not deep enough to be in the area of any of the deep vessels or nerves of the axilla. The subcutaneous tissue was closed with interrupted 3-0 Vicryl and the skin was closed with interrupted 4-0 nylon suture. A sterile dressing was applied. 10 cc of 0.25% Marcaine was injected for local anesthesia. Sterile dressing was applied. The patient tolerated the procedure well.
just a note opath report came back as benign breast parenchyma ?
POSTOPERATIVE DIAGNOSIS: Left axillary mass.
PROCEDURE PERFORMED: Excisional biopsy of left axillary mass.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
CLINICAL HISTORY: A 16-year-old female with a left axillary mass, which has not resolved with oral antibiotics.
PROCEDURE IN DETAIL: The patient was brought into the operating room and placed on the operating table in supine position. The left axilla was prepped and draped in sterile fashion. An elliptical incision was made in the direction of the Langer's lines in the left axilla. Electrocautery was used to dissect through the subcutaneus tissue to excise this soft tissue mass with grossly negative margins. There was no sign of infection. The wound was irrigated with normal saline. It was inspected and found to be hemostatic. Dissection was not deep enough to be in the area of any of the deep vessels or nerves of the axilla. The subcutaneous tissue was closed with interrupted 3-0 Vicryl and the skin was closed with interrupted 4-0 nylon suture. A sterile dressing was applied. 10 cc of 0.25% Marcaine was injected for local anesthesia. Sterile dressing was applied. The patient tolerated the procedure well.
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