hsmith67
Guru
Pt was tender to touch on scalp over "mass" so my surgeon took to the OR to excise the "mass." Following is op note I need help coding.
Once she was positioned, the surgical site on the posterior right head measured approximately 2 cm x 2 cm palpated. The surgical site was prepped and draped in standard surgical fashion. Surgical time-out performed. Surgical site verified. A longitudinal incision was made overlying the mass with a #10 scalpel. There was a pulsatile bleeding small vessel encountered directly under the scalp. The vessel was ligated. The site was explored and no mass found within the subcutaneous tissue. The site was closed with 3-0 Monocryl sutures and skin clip.
Any help coding this is greatly appreciated! I found lots of ligation codes but none that I see appropriate for this procedure. Is this going to be drop to paper and use unlisted code?
Thanks,
Hunter Smith, CPC
Once she was positioned, the surgical site on the posterior right head measured approximately 2 cm x 2 cm palpated. The surgical site was prepped and draped in standard surgical fashion. Surgical time-out performed. Surgical site verified. A longitudinal incision was made overlying the mass with a #10 scalpel. There was a pulsatile bleeding small vessel encountered directly under the scalp. The vessel was ligated. The site was explored and no mass found within the subcutaneous tissue. The site was closed with 3-0 Monocryl sutures and skin clip.
Any help coding this is greatly appreciated! I found lots of ligation codes but none that I see appropriate for this procedure. Is this going to be drop to paper and use unlisted code?
Thanks,
Hunter Smith, CPC