Dr office coded this to CPT 24071(Excision of tumor, elbow area, subcutaneous)
PREOPERATIVE DIAGNOSIS: Left elbow mass.
POSTOPERATIVE DIAGNOSIS: Left elbow mass, a cyst that went down
to the bone. It was an intraosseous cyst that became
extraosseous. There was clear gelatinous fluid and measured
about 7 mm x 7 mm.
PROCEDURE PERFORMED: Excision of the mass and curettage of the
bone with insertion of allograft bone putty.
CLINICAL NOTE: The patient is a 53-year-old gentleman who has
had a mass on the tip of his lateral epicondyle for prolonged
period of time. Every time he banged or hit it, it was quite
uncomfortable for him. He wished to have it excised. The risks
and complications of the procedure including, but not limited to
nerve damage, tendon damage, problems of infection, continued
pain, stiffness, soreness, recurrence, possible diagnosis of
both benign and malignant, as well as others were explained to
him prior to the surgery. He asked me questions and all
questions were answered to his satisfaction, and he signed the
consent form prior to the surgery
DESCRIPTION OF PROCEDURE: The patient was brought to the
operating room and placed in the supine position on the
operating table after receiving IV antibiotics for prophylaxis.
He then had general anesthesia administered by the
anesthesiologist. Once adequate anesthesia was obtained, he had
a tourniquet placed high on his left arm with some Webril and
had his left upper extremity prepped and draped in the normal
sterile fashion. Appropriate time-out was taken. An Esmarch
bandage was used to exsanguinate the arm and tourniquet was
inflated to 250 mmHg. An incision was made directly over the
mass for about 2 cm. The mass was right at the very tip of the
lateral epicondyle. Sharp dissection was carried down through
the skin and blunt dissection. There was an obvious cyst and it
was filled with clear gelatinous fluid. The cyst was excised
and traced down to its stalk. The stalk did emanate from a void
in the bone and went down intraosseous. The bone window was
opened up sightly and then, inside the bone was curettaged out.
It got down the casing of the cyst. Once this was completed, we
got down to a nice bony surface. The wound was copiously
irrigated with sterile irrigant. The void in the bone was then
filled with 1 mL of bone putty to promote healing. The
subcutaneous tissue was then closed with 2-0 Vicryl and skin was
closed with 4-0 nylon. Xeroform and bulky dressings were
applied and tourniquet was deflated with total tourniquet time
of about 14 minutes. He was then brought to the recovery room
in stable condition with good capillary refill on his
fingertips.