Mgd030299batrph
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I am struggling with the following operative note....any suggestion on how I should code this would be greatly appreciated.
Procedure: right inguinal exploration, adenectomy, lymph node removal deep, ligation and resecton of vein with few phleboliths.
Techniques: A 4cm incision was made and extended down into the subcutaneous fatty tissue through Scarpa's and into the area of the superficial ring. In this area there was a large marble sized 1 cm diameter hardness deep to the cord. This was dissected down too, the cord was pulled medially. The area was noted to be a lymph node and was subsequently dissected free of the surrounding fatty tissue. The remaining defect was evaluated and irrigated. The superficial ring and the cord structures were also palpated. The superficial ring was slightly opened to allow the surgeon's finger to be entered into the inguinal canal to assess for an further hernia or defects or nodularity or adenopathy. None was identified, except for the small BBs right at the superficial opening. These were slowly disected, lifted, clipped proximally and distally with the use of ligaclips and then resected. The short section of the two which appeared to be phleboliths were sent to pathology. The superficial ring was then stitched back in a normal configuration with the use of 3-0 Vicryl stitch.
again...any help with coding greatly appreciated!
Procedure: right inguinal exploration, adenectomy, lymph node removal deep, ligation and resecton of vein with few phleboliths.
Techniques: A 4cm incision was made and extended down into the subcutaneous fatty tissue through Scarpa's and into the area of the superficial ring. In this area there was a large marble sized 1 cm diameter hardness deep to the cord. This was dissected down too, the cord was pulled medially. The area was noted to be a lymph node and was subsequently dissected free of the surrounding fatty tissue. The remaining defect was evaluated and irrigated. The superficial ring and the cord structures were also palpated. The superficial ring was slightly opened to allow the surgeon's finger to be entered into the inguinal canal to assess for an further hernia or defects or nodularity or adenopathy. None was identified, except for the small BBs right at the superficial opening. These were slowly disected, lifted, clipped proximally and distally with the use of ligaclips and then resected. The short section of the two which appeared to be phleboliths were sent to pathology. The superficial ring was then stitched back in a normal configuration with the use of 3-0 Vicryl stitch.
again...any help with coding greatly appreciated!