mfournier
Networker
Hello Everyone:
Can someone take a peek at this op note, path states path but not so sure about this op note. Can provider be giving credit for lipoma excision? if his op note states "fascial closure" although it does not mention subcutaneous.
Also, if he cannot be giving credit for lipoma excision, should intermediate layer closure be coded 12031 along with 114xx?
Preoperative diagnosis: Soft tissue mass of the right chest wall and left anterior abdominal wall
Postoperative diagnosis: Same
Procedure: Excision of 4.1 centimeter soft tissue mass of the right chest wall and 9.2 cm soft tissue mass of the left anterior abdominal wall, intermediate multilayered closure of incisions
Anesthesia: Local MAC
Condition: Stable
Complication: None apparent
Specimen: Soft tissue mass of the right chest and soft tissue mass of the left abdominal wall
Drains: None
EBL: 5 mL
Findings: Soft tissue mass as described, consistent with lipomas.
Procedure: The procedure was performed in the operating room. The patient was transferred to the operating table in the supine position. The area was prepped and draped in standard surgical fashion. The area was anesthetized with local anesthetic. Separate incisions were made directly over each of the soft tissue masses and the underlying lipoma was excised completely with a combination of blunt, sharp and electrocautery dissection techniques. They were passed off a specimen. The wound was then closed in multiple layers first with a fascial layer of 3-0 Vicryl followed by superficial fascial layer of 3-0 Vicryl and finally a 4-0 Monocryl intradermal layer. The wound was dressed with Steri-Strips. The patient tolerated the procedure well. All sponge needle and instrument counts correct at the end of the case.
Thank you,
Miriam
Can someone take a peek at this op note, path states path but not so sure about this op note. Can provider be giving credit for lipoma excision? if his op note states "fascial closure" although it does not mention subcutaneous.
Also, if he cannot be giving credit for lipoma excision, should intermediate layer closure be coded 12031 along with 114xx?
Preoperative diagnosis: Soft tissue mass of the right chest wall and left anterior abdominal wall
Postoperative diagnosis: Same
Procedure: Excision of 4.1 centimeter soft tissue mass of the right chest wall and 9.2 cm soft tissue mass of the left anterior abdominal wall, intermediate multilayered closure of incisions
Anesthesia: Local MAC
Condition: Stable
Complication: None apparent
Specimen: Soft tissue mass of the right chest and soft tissue mass of the left abdominal wall
Drains: None
EBL: 5 mL
Findings: Soft tissue mass as described, consistent with lipomas.
Procedure: The procedure was performed in the operating room. The patient was transferred to the operating table in the supine position. The area was prepped and draped in standard surgical fashion. The area was anesthetized with local anesthetic. Separate incisions were made directly over each of the soft tissue masses and the underlying lipoma was excised completely with a combination of blunt, sharp and electrocautery dissection techniques. They were passed off a specimen. The wound was then closed in multiple layers first with a fascial layer of 3-0 Vicryl followed by superficial fascial layer of 3-0 Vicryl and finally a 4-0 Monocryl intradermal layer. The wound was dressed with Steri-Strips. The patient tolerated the procedure well. All sponge needle and instrument counts correct at the end of the case.
Thank you,
Miriam