tfrick2
Networker
I can't decide the best way to code this one, either 11423 or 13132:
INDICATIONS: The patient is a 46-year-old male who has had a painful
lesion on the plantar aspect of the left foot between the fourth and fifth
metatarsal head for a number of months. The patient denied any injury. An
ultrasound of the lesion revealed only scar tissue. The patient was taken
to the operating room to have the lesion removed to relieve the pain. The
operative procedure, postoperative care, and postoperative complications
including but not limited to pain, swelling, infection, and possible return
of the deformity had been explained to the patient. The patient
acknowledged and agreed to surgery and the consent form was signed.
PROCEDURE: The patient was taken to the operating room and placed on the
operating room table in the supine position. A member of the anesthesia
team administered intravenous sedation while the surgeon administered local
infiltrative block to the left foot. The left foot was then prepped and
draped in normal sterile fashion. Anesthesia was tested and found to be
adequate. Esmarch was placed above the left ankle for hemostasis.
Attention was then turned to the plantar aspect of the left foot. Two
semielliptical incisions were made to surround the lesions. At this point,
the patient related response to painful stimulus and an additional 10 mL of
Xylocaine was then administered and anesthesia was achieved. The incision
was deepened full-thickness to the level of the adipose tissue and the
elliptical portion of the skin was removed in toto. It was measured
approximately 3x1x1.5 in size. The tourniquet was released. The wound was
copiously irrigated using sterile saline. The wound was then closed using
3-0 nylon suture. The patient tolerated the procedure well without
complications. A dry dressing was placed on the left foot."
The pathology report says "Epidermis with dense stromal tissue consistent with scar."
INDICATIONS: The patient is a 46-year-old male who has had a painful
lesion on the plantar aspect of the left foot between the fourth and fifth
metatarsal head for a number of months. The patient denied any injury. An
ultrasound of the lesion revealed only scar tissue. The patient was taken
to the operating room to have the lesion removed to relieve the pain. The
operative procedure, postoperative care, and postoperative complications
including but not limited to pain, swelling, infection, and possible return
of the deformity had been explained to the patient. The patient
acknowledged and agreed to surgery and the consent form was signed.
PROCEDURE: The patient was taken to the operating room and placed on the
operating room table in the supine position. A member of the anesthesia
team administered intravenous sedation while the surgeon administered local
infiltrative block to the left foot. The left foot was then prepped and
draped in normal sterile fashion. Anesthesia was tested and found to be
adequate. Esmarch was placed above the left ankle for hemostasis.
Attention was then turned to the plantar aspect of the left foot. Two
semielliptical incisions were made to surround the lesions. At this point,
the patient related response to painful stimulus and an additional 10 mL of
Xylocaine was then administered and anesthesia was achieved. The incision
was deepened full-thickness to the level of the adipose tissue and the
elliptical portion of the skin was removed in toto. It was measured
approximately 3x1x1.5 in size. The tourniquet was released. The wound was
copiously irrigated using sterile saline. The wound was then closed using
3-0 nylon suture. The patient tolerated the procedure well without
complications. A dry dressing was placed on the left foot."
The pathology report says "Epidermis with dense stromal tissue consistent with scar."