codedog
True Blue
my supervisor wants me to code it as 11406 with a closeure of 12032, i says its 21552- excision tumor- subcutaneous 3cm or greater of neck or anterior thorax- - I hate to be wrong , hope I am not ,path report confirmed a lipoma - what don you think ?
POSTOPERATIVE DIAGNOSIS: Left chest wall mass in a patient with a personal history of breast carcinoma.
PROCEDURE PERFORMED: Excision of left chest wall mass around 5 cm with two-layer closure.
PERATIVE PROCEDURE: After appropriate informed consent was signed, the patient was taken to the operating room and was transferred to the operating table and underwent general anesthesia with endotracheal intubation. The area was prepped and draped by me with DuraPrep solution and five minutes was waited prior to using Bovie catheterization. The patient was then marked by me in the preoperative holding area. An incision directly over the mass in a horizontal fashion was made for around 5-6 cm. Dissection was carried down through the skin and subcutaneous tissue. So, I got to do the subdermal and what appeared to be clinically a lipoma was removed, although it was a little different than other surrounding fat in color and in slight texture. All of this was removed. It was around 5-6 cm. It was sent to pathology for permanent sectioning. Excellent hemostasis was noted. The area was irrigated. There was found to be excellent hemostasis. The wound was then closed in deeper layers with 3-0 Vicryl interrupted and 3-0 nylon was used on the skin. Sterile dressing was placed. The patient tolerated the procedure and transferred to the recovery room in a stable condition.
POSTOPERATIVE DIAGNOSIS: Left chest wall mass in a patient with a personal history of breast carcinoma.
PROCEDURE PERFORMED: Excision of left chest wall mass around 5 cm with two-layer closure.
PERATIVE PROCEDURE: After appropriate informed consent was signed, the patient was taken to the operating room and was transferred to the operating table and underwent general anesthesia with endotracheal intubation. The area was prepped and draped by me with DuraPrep solution and five minutes was waited prior to using Bovie catheterization. The patient was then marked by me in the preoperative holding area. An incision directly over the mass in a horizontal fashion was made for around 5-6 cm. Dissection was carried down through the skin and subcutaneous tissue. So, I got to do the subdermal and what appeared to be clinically a lipoma was removed, although it was a little different than other surrounding fat in color and in slight texture. All of this was removed. It was around 5-6 cm. It was sent to pathology for permanent sectioning. Excellent hemostasis was noted. The area was irrigated. There was found to be excellent hemostasis. The wound was then closed in deeper layers with 3-0 Vicryl interrupted and 3-0 nylon was used on the skin. Sterile dressing was placed. The patient tolerated the procedure and transferred to the recovery room in a stable condition.