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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Please use your textbook, study materials, and a good search engine or two to find your answers.
1. Go to http://www.google.com or http://www.bing.com
2. Type in cpt codes (or whatever search terms you need). Press Enter.
3. Read different search results until you find what you need.
4. Re-search with different search terms if you don't find all you need.
To determine the CPT code and ICD-9-CM code, we need to analyze the information provided in the operative report.
CPT codes are used to identify specific medical procedures, while ICD-9-CM codes are used to classify diagnoses.
Looking at the operative report, here is how we can determine the appropriate codes:
1. CPT Code: In this case, the operative procedure performed is the "Excision of left flank soft tissue mass with layered closure measuring 4 cm, with margins, prior to excision". To find the corresponding CPT code, we can search for the relevant procedure in the CPT code manual. Based on the description, the most appropriate CPT code would be 11402 - Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm. This code indicates that the excision was performed on a benign lesion on the trunk.
2. ICD-9-CM Code: The preoperative and postoperative diagnosis is "Left flank soft tissue mass". To determine the ICD-9-CM code, we can search for the diagnosis in the ICD-9-CM code manual. The most relevant code would be 238.2 - Neoplasm of uncertain behavior of connective and other soft tissue. This code indicates a soft tissue mass with uncertain behavior.
Therefore, the CPT code for this operative report is 11402, and the ICD-9-CM code is 238.2.