Medical Billing & Coding

posted by Arlene

You've started your first day at Venture Outpatient Surgery Center. Code the Following operative report:

Operative Report
PREOPERATION DIAGNOSIS: Left flank soft tissue mass
POSTOPERATIVE DIAGNOSIS: Left flank soft tissue mass
SURGEON: John Doe, DO
OPERATIONS: Excision of left flank soft tissue mass with layered closure measuring 4 cm, with margins, prior to excision
ANESTHESIA: Sedation with 1% lidocaine with epinephrine and sodium bicarbonate
OPERATIVE INDICATIONS: This is a pleasant female who comes in with a soft tissue lesion in the left flank over what appeared to be a spigelian hernia site as well. However, it was not reducible and did not appear to be consistent with a hernia. Consequently, the procedure, risks, benefits, and alternatives of excision of this lesion were discussed with the patient, and she understood and wished to proceed with the excision.
OPERATIVE FINDINGS: Large soft tissue lesion measuring about 6 cm in greatest dimension
OPERATIVE PROCEDURE: The patient was brought into the operation room after informed consent was obtained. The patient then underwent sedation with a sterile prep and drape. We then anesthetized with 1% lidocaine with epinephrine and sodium bicarbonate, made a 4-cm incision, and used sharp dissection to dissect circumferentially around this soft tissue lesion, being careful to make sure that we were not entering any kind of hernia sac secondary to spigelian hernia. As we continued to dissect circumferentially aruond it without sharp dissection, it was noted that it did go down to a muscle, but no evidence of hernia was identified. The lesion was excised in its entirety, and electrocautery was used to control hemostasis. We then irrigated with saline solution and closed with esubcutaneous tissue with 3-0 Vicryl interrupted and running sutures. We then used 4-0 Vicryl sutures to close the skin in a subcuticular fashion. Benzoin and Steri-Strips were then applied. Blood loss was minimal. The patient tolerated the procedure well and remained in stable condition throughout the procedure.

CPT Code:________________
ICD-9-CM Code:___________________

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