After informed consent was obtained, the area of the lesion was prepped and draped in standard sterile fashion with Chlorhexidine solution. Pre-emptive analgesia was applied with 1% lidocaine with epinephrine solution prior to incision. After adequate pain control was achieved, a 2 cm incision, enlarged to 2.75cm for better visibility, was made along lines of least tension, and dissection was carried out to muscle fascia, which revealed a palpable defect. At that time, Dr. came in and examined the patient as well. He agreed that the exam is consistent with a small muscle hernia. There is a small piece of fat protruding through the muscle defect. At that time, the risks and benefits of a closure without any release of tension was discussed and, given the high level of recurrence with such a procedure, the patient decided that he would like to postpone any procedure at this time. The incision was closed with 3-0 dermal monocryl sutures, Steri-strips were placed, covered with a Tegaderm, then a sterile bandage was applied, covered by a Tegaderm.
Would it just be the incision and drainage code 27603?
Thanks for any help you can provide!