Can someone please give me some direction on this one? Is there a code that I'm missing or do I need to use an unlisted? If so, what would be your suggestion for a comparison code? Thanks so much!
PREOPERATIVE DIAGNOSIS: CYST, RIGHT STERNOCLAVICULAR JOINT.
POSTOPERATIVE DIAGNOSIS: MUSCLE HERNIA, STERNOCLEIDOMASTOID, RIGHT
STERNOCLAVICULAR JOINT.
OPERATION: EXPLORATION OF MASS.
DECOMPRESSION OF HERNIATED MUSCULAR
TISSUE THROUGH DEFECT IN FASCIA.
OPERATIVE FINDINGS: This is a 34 -year-old female with a history of ST who has had a mass in the region of the right sternoclavicular joint for an extended period of time... There were no systemic symptoms. The mass was a nuisance to her, and it was mobile... the decision was made to explore the mass, acknowledging that it may not be resected...
Pathology: a 1 x 1 cm soft mobile mass was identified intraoperatively. The mass itself was red in appearance and had the appearance of herniated muscle tissue through a defect in the fascial plane. Of note, the mass was not fluid-filled, but it was quite mobile, and it was not firm.
OPERATIVE PROCEDURE:...a transverse incision was made directly over the palpable mass in line with the clavicle. The incision was deepened through the subcutaneous tissue and circumferential dissection was performed. The mass was easily encountered. It was then dissected down through the fascial plane overlying the playtismus muscle. There was a defect in this fascial plane, and it appeared that the mass itself was hypertrophied and thickened muscular tissue. It was mobile. The fascia was then split for approximately 3 mm medially and 3 mm laterally, and the mass itself then reduced and retracted. There was some subcutaneous tissue in the area surrounding the mass, and that was resected, but this tissue was not cyst-like in nature. The sternocleidomastoid, deep cervical fascial tissue,and fascia overlying the clavicle appeared in tact and were not edematous. Great care was taken to protect all neurovascular structures and superficial nerves, which were preserved using retractors and careful dissection throughout the procedure. The wound was then copiously irrigated with normal saline solution. Subcutaneous tissues were closed with 3-0 Vicryl sutures. The skin was closed with running Monocryl suture.
PREOPERATIVE DIAGNOSIS: CYST, RIGHT STERNOCLAVICULAR JOINT.
POSTOPERATIVE DIAGNOSIS: MUSCLE HERNIA, STERNOCLEIDOMASTOID, RIGHT
STERNOCLAVICULAR JOINT.
OPERATION: EXPLORATION OF MASS.
DECOMPRESSION OF HERNIATED MUSCULAR
TISSUE THROUGH DEFECT IN FASCIA.
OPERATIVE FINDINGS: This is a 34 -year-old female with a history of ST who has had a mass in the region of the right sternoclavicular joint for an extended period of time... There were no systemic symptoms. The mass was a nuisance to her, and it was mobile... the decision was made to explore the mass, acknowledging that it may not be resected...
Pathology: a 1 x 1 cm soft mobile mass was identified intraoperatively. The mass itself was red in appearance and had the appearance of herniated muscle tissue through a defect in the fascial plane. Of note, the mass was not fluid-filled, but it was quite mobile, and it was not firm.
OPERATIVE PROCEDURE:...a transverse incision was made directly over the palpable mass in line with the clavicle. The incision was deepened through the subcutaneous tissue and circumferential dissection was performed. The mass was easily encountered. It was then dissected down through the fascial plane overlying the playtismus muscle. There was a defect in this fascial plane, and it appeared that the mass itself was hypertrophied and thickened muscular tissue. It was mobile. The fascia was then split for approximately 3 mm medially and 3 mm laterally, and the mass itself then reduced and retracted. There was some subcutaneous tissue in the area surrounding the mass, and that was resected, but this tissue was not cyst-like in nature. The sternocleidomastoid, deep cervical fascial tissue,and fascia overlying the clavicle appeared in tact and were not edematous. Great care was taken to protect all neurovascular structures and superficial nerves, which were preserved using retractors and careful dissection throughout the procedure. The wound was then copiously irrigated with normal saline solution. Subcutaneous tissues were closed with 3-0 Vicryl sutures. The skin was closed with running Monocryl suture.
