What does test result "Large soft tissue lesion" mean?
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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
Posted Mon, 23 Dec 2013 in Abdominal Pain
Answered by Dr. Shoaib Khan 12 hours later
Brief Answer: Soft tissue growth; histologically unidentified Detailed Answer: Hello ma'am and welcome. Thank you for writing to us. Code 729.90 seems most accurate to me ma'am.. For youe satisfaction I shall help you with the operational report also as requested by you. The operation report would be: A soft tissue lesion wqs identified and found. During surgery, the approach was to go around the lesion without damaging surrounding structures and to sucessfully excise/remove the lesion which is currently unidentified histologically. Excised tissue of the soft tissue mass/growth/tumor, will then be sent to the laboratory for a histological examination (report not mentioned in your query). No signs of a hernia were seen or reported. Surgery was successful and the entire mass was successfully excised/removed without signs of any malignancy or complications or residual tissue. I hope this is more clear now ma'am. But if there is any other information or clarification you need assistance with I shall be obliged to help you. Please feel free to write to me with the queries you have. Best wishes.
Follow-up: What does test result "Large soft tissue lesion" mean? 3 days later
I did not get the result from in Instructor on this report yet. But thank you for the explanation about my operative report scenario.
Answered by Dr. Shoaib Khan 1 hour later
Brief Answer: You are most welcome Detailed Answer: Hello once again ma'am. You are most welcome ma'am. Please feel free to write to me about any health-related queries. I would be more than happy to help. God bless.
Follow-up: What does test result "Large soft tissue lesion" mean? 2 days later
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.
Answered by Dr. Shoaib Khan 40 minutes later
Brief Answer: My sincere apologies for the code error Detailed Answer: Hello ma'am. My apologies for the code as our country does not pay much emphasis on codes, which is why I informed you in advance about my inability to be able to provide you with the right code, which is why I preferred explaining the operation details to you. I hope you found my response on the operation details helpful. Please feel free to write back to me regarding any further clarifications, or health-related issues, and I would be more than happy to help you. God bless.
Follow-up: What does test result "Large soft tissue lesion" mean? 24 hours later
Thank you. It's not a problem at all. Have a good day!
Answered by Dr. Shoaib Khan 2 minutes later
Brief Answer: Completely my pleasure Detailed Answer: Hello once again ma'am. Completely my pleasure, please feel free to keep in touch and write to me for any further health-related issues (god forbid you would ever have any). Best wishes.
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