I appreciate any help
Help Excision Soft Tissue Mass Finget
I appreciate any help
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Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page 2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers Click here for more sample CPC practice exam questions and answers with full rationale 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.
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AAPC Knowledge Center
In ICD-10: N63 series is female gender specific codes. Can we go with R22.2 for male breast mass??
Thank you:D:confused:!!
15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
The patient has a 50 cm x 20 cm Lymphedema Mass . The mass was excised by direct excision and closed with a Local Tissue Rearrangement.
Patient was brought to the operating suite, placed in the lithotomy position, prepped and draped in the usual sterile fashion. After adequate general anesthesia was obtained, Ancef was given preoperatively. The cystoscope was inserted per urethra after a time-out was performed. The urethra was normal. Prostatic lobes were seen and enlarged. There was a median lobe kind of pointing over a little bit to his right side. Bilateral ureteral orifices were normal. Bladder was normal, but there was a cystic lesion that was anterior, but if you followed it, it actually seemed to attach more laterally on the left prostatic lobe bladder neck area extending into the bladder. Went ahead and did some biopsies of it with just a cold cup and sent it off separately to Pathology and then used the loop to resect the area on the prostate without any difficulty. Ellik was used to remove the chips. Hemostasis was excellent. The chips were sent separately as a specimen too of that prostatic mass area on the left lobe. At the end of the procedure, there were no specimens. The bladder was clear. Went ahead and left some fluid in and removed the cystoscope. A Foley catheter was placed without any difficulty and was put to drainage.
I am at a lose as to how to code for masses in the 12-3-6-9 oclock positions. The new codes are for UIQ, UOQ, LIQ and LOQ, with a code for unspecified quadrant.
Unlike the Breast Cancer codes which has a overlapping code for those positions.
I have been using the unspecified quadrant codes but I don’t like to use that. Any help would be great.
Thanks so much for your help
Michelle L English CPC