I am new to Urology coding and I'm having a hard time with an op note. I feel like it should be coded as 54512-RT and maybe 54860-52-RT.
I'm curious what the experienced Urology coder would code this note as:
Pre-op Diagnosis: Right Paratesticular mass
Post-op Diagnosis: Same
Procedure:
1. Inguinal exploration of part testicle mass
2. Resection of particulate mass
3. Orchidopexy right
After an informed consent was obtained the patient was transferred to the operate suite and place on the OR table in supine position. General anesthesia was induced. Preoperative antibiotics were given in the OR, including Ancef 1 gram IV x 1 for per operative coverage. A surgical time-out was obtained to identify the correct patient, correct procedure, correct procedural site. The patient was transpositioned into the froleg position and all pressure points were padded. The genitals were prepped and draped in a usual sterile fashion. An approximately 2 inch right inguinal incision incision was made. Subcutaneous fat was transected with electrocautery. The external oblique fascia was identified and incised sharply. The spermatic cord was identified, freed up from surrounding tissues and circled with a prenrose drain tightly. The right testis was pushed into the surgical. The tunic dartos was incised, the testis explored and the prior testicular mass identified. The paratesticular mass was excised sharply. No bleeding was identified. The paratesticular mass was sent for pathology. A frozen section was requested. The 2 knees are dartos was closed with a running 5-0 monocryl. Frozen section confirmed benign mass, sperm granuloma. Orchidopexy was performed using 3 0 vicryl. The testis was repositioned into the scrotum. The spermatic cord was not twisted at this point. The fascia was closed with a running 3 0 PDS. The subcutaneous fat was reapproximated with interrupted 3 0 vicryl sutures. The skin was closed iwth a 5 0 monocyryl suture in a subcuticular manner. 20cc of 0.25 percent marcaine was used for local anesthetic. Dry dressing was applied.
Any help is greatly appreciated!!
I'm curious what the experienced Urology coder would code this note as:
Pre-op Diagnosis: Right Paratesticular mass
Post-op Diagnosis: Same
Procedure:
1. Inguinal exploration of part testicle mass
2. Resection of particulate mass
3. Orchidopexy right
After an informed consent was obtained the patient was transferred to the operate suite and place on the OR table in supine position. General anesthesia was induced. Preoperative antibiotics were given in the OR, including Ancef 1 gram IV x 1 for per operative coverage. A surgical time-out was obtained to identify the correct patient, correct procedure, correct procedural site. The patient was transpositioned into the froleg position and all pressure points were padded. The genitals were prepped and draped in a usual sterile fashion. An approximately 2 inch right inguinal incision incision was made. Subcutaneous fat was transected with electrocautery. The external oblique fascia was identified and incised sharply. The spermatic cord was identified, freed up from surrounding tissues and circled with a prenrose drain tightly. The right testis was pushed into the surgical. The tunic dartos was incised, the testis explored and the prior testicular mass identified. The paratesticular mass was excised sharply. No bleeding was identified. The paratesticular mass was sent for pathology. A frozen section was requested. The 2 knees are dartos was closed with a running 5-0 monocryl. Frozen section confirmed benign mass, sperm granuloma. Orchidopexy was performed using 3 0 vicryl. The testis was repositioned into the scrotum. The spermatic cord was not twisted at this point. The fascia was closed with a running 3 0 PDS. The subcutaneous fat was reapproximated with interrupted 3 0 vicryl sutures. The skin was closed iwth a 5 0 monocyryl suture in a subcuticular manner. 20cc of 0.25 percent marcaine was used for local anesthetic. Dry dressing was applied.
Any help is greatly appreciated!!