tdesher
Networker
Can someone help me, I am billing for an ASC and a case was put on here to remove a mass from a patients forehead but when he got in there, the Dr realized it was just bone so ended up not removing anything. How would I code this as EUA? See op report below
PREOPERATIVE DIAGNOSIS: Left forehead mass.
POSTOPERATIVE DIAGNOSIS: Left forehead bony mass.
PROCEDURE PERFORMED: Examination of left forehead mass under anesthesia.
FINDINGS: 1.2 cm left forehead fixed bony mass.
DESCRIPTION OF PROCEDURE: I first focussed my attention to the left forehead region. I confirmed the preoperative surgical markings, and infiltrated the subcutaneous tissues surrounding these utilizing local anesthetic. I then utilized a #15 blade scalpel and made a full-thickness skin incision overlying these markings. I then dissected through the subcutaneous tissue, and it was apparent that the mass was in the submuscular region. The muscular fibers were then divided along their length and this revealed an underlying bony mass. This was affixed to the surrounding frontal bone. At this point, I decided do not proceed further with dissection or removal as this was a bony mass affixed to the surrounding bone necessitating further evaluation prior to proceeding. The surgical site was irrigated with copious amounts of normal saline and again, meticulous hemostasis was achieved throughout utilizing electrocautery. Again, meticulous hemostasis was achieved with electrocautery, I then proceeded with closure. The subcutaneous tissue and deep dermis were reapproximated utilizing inverted interrupted 3-0 Monocryl suture. Instrument, sponge, and needle count were correct x 2 at the end of the procedure. Dermabond was then applied.
PREOPERATIVE DIAGNOSIS: Left forehead mass.
POSTOPERATIVE DIAGNOSIS: Left forehead bony mass.
PROCEDURE PERFORMED: Examination of left forehead mass under anesthesia.
FINDINGS: 1.2 cm left forehead fixed bony mass.
DESCRIPTION OF PROCEDURE: I first focussed my attention to the left forehead region. I confirmed the preoperative surgical markings, and infiltrated the subcutaneous tissues surrounding these utilizing local anesthetic. I then utilized a #15 blade scalpel and made a full-thickness skin incision overlying these markings. I then dissected through the subcutaneous tissue, and it was apparent that the mass was in the submuscular region. The muscular fibers were then divided along their length and this revealed an underlying bony mass. This was affixed to the surrounding frontal bone. At this point, I decided do not proceed further with dissection or removal as this was a bony mass affixed to the surrounding bone necessitating further evaluation prior to proceeding. The surgical site was irrigated with copious amounts of normal saline and again, meticulous hemostasis was achieved throughout utilizing electrocautery. Again, meticulous hemostasis was achieved with electrocautery, I then proceeded with closure. The subcutaneous tissue and deep dermis were reapproximated utilizing inverted interrupted 3-0 Monocryl suture. Instrument, sponge, and needle count were correct x 2 at the end of the procedure. Dermabond was then applied.