Wednesday
July 30, 2014

Homework Help: Medical Coding

Posted by Cuki on Monday, January 4, 2010 at 11:43pm.

Fill In The Blank.
Read the following report(s) to answer the fill in the blank questions. Place the correct code(s) in the space provided. If more than one code is necessary separate the codes with a comma.

Operative Report
INDICATIONS: The patient is seen for excision of skin lesions of the left ankle and a hemangioma of the waistline with recent changes including size, color/pigment, and chronic irritation with bleeding.

PROCEDURES:

Excision of a 2.5 cm hemangioma on the waistline with extensive undermining and closure.
Excision of suspicious 1.5 cm lesion of the left ankle with extensive undermining and closure.
OPERATION IN DETAIL: After sterile preparation and draping in the normal sterile fashion and local anesthetic, the lesions were approached. The ankle lesion was elliptically excised. Extensive undermining was required in order to close the large defect caused, since the halos of the lesion also required excision.

After extensive undermining, the deepest layer was closed with 3-0 PDS, the more intermediate layer was closed with 4-0 PDS, and the most superficial layer was closed with 5-0 PDS suture, followed by treatment with Dermabond and Steri-Strip placement.

Next, attention was then turned to the hemangioma on the waistline. This was not only completely excised, but it was also cauterized in order to prevent bleeding afterwards, and it was also closed using the deep 3-0 PDS suture, followed by the 4-0 PDS suture, and finally followed by the 5-0 PDS suture. Dermabond and Steri-Strips were also placed on this.

The patient tolerated the procedure well. No complications occurred throughout. Due to the lesions being fairly complex in nature, compared to the average skin lesions, the patient was placed on antibiotics post procedure. She will follow up sometime in the next few weeks for re-evaluation, sooner if she has any problems.

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