Hello! If someone can pls assist me with this op note, it will be highly appreciated. Thanks!
PREOPERATIVE DIAGNOSIS: Vaginal cyst.
POSTOPERATIVE DIAGNOSIS: Vaginal mass.
PROCEDURE PERFORMED: Biopsy of vaginal mass.
DESCRIPTION OF PROCEDURE: After an informed consent was obtained, the patient was taken to the operating room where she was prepped and draped in a normal sterile fashion in Candy Cane stirrups. She was placed under MAC anesthesia. The vagina was inspected and a palpable cystic lesion was felt at around 11 o'clock at the perineum that extended very close to the anal sphincter. The vagina was infiltrated with 1 % lidocaine with epinephrine and using a scalpel incised down to the level of the palpable mass. Once the level of the palpable mass was reached , no cyst wall was noted and no cystic fluid was encountered. However, firm, tan, and yellowish tissue with some areas of darker brown to blackish spots were noted. This mass was extended fairly close to the anal sphincter and due to the proximity to the anal sphincter, excision of the entire mass was not attempted; however, a biopsy of the mass was performed and this was sent to Pathology. The vaginal tissue overlying the mass was then closed in layers using 3-0 Vicryl and then the skin was closed with 4-0 Vicryl. Excellent hemostasis was noted throughout. The patient was taken to the recovery room in stable condition.
CPT code 57105 or 57135??
PREOPERATIVE DIAGNOSIS: Vaginal cyst.
POSTOPERATIVE DIAGNOSIS: Vaginal mass.
PROCEDURE PERFORMED: Biopsy of vaginal mass.
DESCRIPTION OF PROCEDURE: After an informed consent was obtained, the patient was taken to the operating room where she was prepped and draped in a normal sterile fashion in Candy Cane stirrups. She was placed under MAC anesthesia. The vagina was inspected and a palpable cystic lesion was felt at around 11 o'clock at the perineum that extended very close to the anal sphincter. The vagina was infiltrated with 1 % lidocaine with epinephrine and using a scalpel incised down to the level of the palpable mass. Once the level of the palpable mass was reached , no cyst wall was noted and no cystic fluid was encountered. However, firm, tan, and yellowish tissue with some areas of darker brown to blackish spots were noted. This mass was extended fairly close to the anal sphincter and due to the proximity to the anal sphincter, excision of the entire mass was not attempted; however, a biopsy of the mass was performed and this was sent to Pathology. The vaginal tissue overlying the mass was then closed in layers using 3-0 Vicryl and then the skin was closed with 4-0 Vicryl. Excellent hemostasis was noted throughout. The patient was taken to the recovery room in stable condition.
CPT code 57105 or 57135??
