Question: PREOPERATIVE DIAGNOSIS: Left flank soft tissue mass POSTOPERATIVE DIAGNOSIS: Left flank soft tissue mass OPERATIONS: Excision of left flank soft tissue mass with layered closure measuring 4cm, with margins, prior to excision. ANESTHESIA: Sedation with 1% lidocaine with epinephrine and sodium bicarbonate OPERATIVE INDICATION: This is 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 alternative of excision of this lesion were discussed with the patient, and she understood and wished to proceed with excision. OPERATIVE FINDINGS: Large soft tissue lesion measuring about 6cm 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 s harp 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 around 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 the subcatenous tissue with 3-0 Vicryl interrupted and running sutures. We then used 4-0 Vicryl sutures to close the skin in a subcuticural 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. I supposed to provide CPT code and ICD-9-CM code. I come up with 21933-LT and 215.7 for answers. But I also discovered another codes that might be the correct one: 239.2 (bones, soft tissue, and skin) and 729.90 (disorders of soft tissue, unspecified). Please provide me the right codes or explanation for the operative report. Thank you.Also, it identified the surgeon name in this operative report. SURGEON: XXXXXXX Doe, DO

I did not get the result from in Instructor on this report yet. But thank you for the explanation about my operative report scenario.

Hi Dr. Shoaib XXXXXXX I just got my exam result from my Instructor.It is unfortunately wrong the ICD-9-CM code 729.90 . Instructor did not provide the right one. However, thank you for review about operative report.

Thank you. It's not a problem at all. Have a good day!