rrrobinson05
Contributor
Need help with a CPT code. I am looking at 21601 but this procedure does not include ribs. Any insight into this is very much appreciated. Here's the Op Note:
Indications: ______ is a 16 y.o. male presenting with a right axillary mass. An incisional biopsy last week was suspicious for a lipoblastoma. He is here today for a formal resection with margins. I apprised his mother to the risks and benefits of the procedure and she requested that I proceed. Weight: 62.9 kg (138 lb 10.7 oz)
Operative Details: ______ was brought to the operating room where he underwent general anesthesia. David was then prepped and draped in the usual fashion. An obliquely oriented ellipse was performed encompassing the prior incisional biopsy. Skin flaps were raised circumferentially overlying the mass. Dissection thein proceeded from medial to inferior. There was no evidence of invasion of the chest wall or musculature. The posterior aspect of the mass densely adherent to the axillary lymphatics. The long thoracic nerve was identified and its entire axillary course was dissected free from the posterior surface. The degree of adherence was concerning but I did not feel that the pathology warranted resection of the nerve. The superior aspect of the mass was easily dissected way from the chest wall beneath the pectoralis major. The superior aspect of the tumor ended at the level of the axillary vein. The remaining tissue was taken using sharp dissection to avoid injury to the nerve in the is region. The 14X8 cm mass was sent for permanent. The specimen was marked with a silk suture. Long double superior. Long single lateral. Short medial. Hemostasis was excellent. A 15 french round blake was placed inferiorly. The deep dermis was closed with a running 3-0 vicryl. The skin was closed with a running 3-0 monocryl. The wound was dressed with dermabond, steristrips, telfa and tegaderm.
14 cm x 8 cm mass
Indications: ______ is a 16 y.o. male presenting with a right axillary mass. An incisional biopsy last week was suspicious for a lipoblastoma. He is here today for a formal resection with margins. I apprised his mother to the risks and benefits of the procedure and she requested that I proceed. Weight: 62.9 kg (138 lb 10.7 oz)
Operative Details: ______ was brought to the operating room where he underwent general anesthesia. David was then prepped and draped in the usual fashion. An obliquely oriented ellipse was performed encompassing the prior incisional biopsy. Skin flaps were raised circumferentially overlying the mass. Dissection thein proceeded from medial to inferior. There was no evidence of invasion of the chest wall or musculature. The posterior aspect of the mass densely adherent to the axillary lymphatics. The long thoracic nerve was identified and its entire axillary course was dissected free from the posterior surface. The degree of adherence was concerning but I did not feel that the pathology warranted resection of the nerve. The superior aspect of the mass was easily dissected way from the chest wall beneath the pectoralis major. The superior aspect of the tumor ended at the level of the axillary vein. The remaining tissue was taken using sharp dissection to avoid injury to the nerve in the is region. The 14X8 cm mass was sent for permanent. The specimen was marked with a silk suture. Long double superior. Long single lateral. Short medial. Hemostasis was excellent. A 15 french round blake was placed inferiorly. The deep dermis was closed with a running 3-0 vicryl. The skin was closed with a running 3-0 monocryl. The wound was dressed with dermabond, steristrips, telfa and tegaderm.
14 cm x 8 cm mass