PRE-OPERATIVE DIAGNOSIS: Left breast mass POSTOPERATIVE DIAGNOSIS: Pending pathology This 45-year-old female patient found a suspicious lump in her left breast. Mammogram completed last week revealed a suspicious area in the left breast. There were no other findings from the mammogram. PROCEDURE: General anesthesia was administered. The left breast was prepped and draped in the normal sterile fashion. A 3-cm-long incision was made in the upper portion of the breast. Cautery dissection was used to elevate the skin flaps. Hemostasis was achieved and the dissection was carried down to remove the tissue and a biopsy was taken. The specimen was sent to pathology. The wounds were carefully closed and dressed. There were no complications and there was minimal blood loss.
ICD-10 PCS code is a procedure coding system
Excision of left breast, open approach - 0HBU0ZX
ICD-10 cm code
Lump in the breast -N63
PRE-OPERATIVE DIAGNOSIS: Left breast mass POSTOPERATIVE DIAGNOSIS: Pending pathology This 45-year-old female patient fou...
Operative Report PRE- AND POSTOPERATIVE DIAGNOSIS: Hydrocele ANESTHESIA: General Under general anesthesia, this 36-year-old male was prepped and draped in the usual fashion. After placing the patient in the lithotomy position, a 3.5-cm incision was made in the left marsupium and a hydrocele was visualized. Hemostasis was achieved. The hydrocele was located in the tunica vaginalis and was dissected and brought through the incision site. The hydrocele was surgically excised, and a drain was placed. The wound was closed in...
PRE-OPERATIVE DIAGNOSIS: Orbital lesion, OS-left eye POSTOPERATIVE DIAGNOSIS: Orbital lesion, pathology pending PROCEDURE: Patient was prepped with proparacaine instilled in the left eye and 2% Lidocaine with 1:200,000 epinephrine injected in the superior aspect of the left orbit. The upper lid was everted and a herniated lesion was located and measured at 0.50 cm in diameter. The herniated lesion was clamped and excised. Cauterization was then used to stop the bleeding. The mass was sent to pathology. The superior fornix...
LOCATION: Inpatient, Hospital PATIENT: Charlene Tipton SURGEON: Loren White, M.D. PRE/POSTOPERATIVE DIAGNOSIS: Right breast mass. PROCEDURE(S) PERFORMED: Right breast open biopsy. ANESTHESIA: General endotracheal. INDICATIONS: Charlene is a 66-year-old female who presented with a palpable right breast mass. A biopsy was done which showed atypical cells and was felt to be suspicious for cancer. She also had a highly suspicious lesion on ultrasound in the same area. An open biopsy was recommended. Possible definitive treatment with simple mastectomy was also...
Pre- and Postoperative Diagnosis ANESTHESIA: General This 64-year-old female patient was taken to the OR and placed in the supine position. An upper midline incision was made and retractors were placed. The LUQ was explored and splenic ligaments and the gastric veins were identified and divided. Dissection at the splenic hilum occurred and the splenic vessels were identified. The splenic artery and vein were double ligated, suture ligated, and divided. The entire spleen was removed and hemostasis was achieved. Blood...
Loren White, M.D. PREOPERATIVE DIAGNOSIS: Mass, right axilla, history of breast cancer. POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: Biopsy of mass, right axilla. PRELIMINARY NOTE: This patient had a mastectomy six years ago and had positive nodes at that time. Recently, she presented with a fixed mass in the right axilla, and after a good deal of discussion, she decided to have a biopsy done. We did a true cut needle biopsy and obtained a diagnosis of metastatic cancer. The patient...
Thank you. Code(s): Operative Report #2 Operative Report Breast carcinoma Preoperative Diagnosis: Postoperative Diagnosis: Operation: Same Removal of venous access port The patient is a 44-year-old woman who had a left, modified radical mastectomy in 2010. In August she had a Port-a-cath placed in the right side. However it has caused an extreme amount of discomfort, so she has requested that it be removed. The patient was taken to the OR and placed in a supine position on the table....
code with icd 10 pcs Operative Report AFOPERATIVE DIAS ATIVE DIAGNOSIS: Gangrene of the left foot ERATIVE DIAGNOSIS: Gangrene of the left foot Left below-knee amputation ASTOPERATIVE DIAGA OPERATION: NDICATIONS FOR ONS FOR SURGERY: This is an 86-year-old male who has a history of vasculitis, and peripheral disease, who presents with gangrene of the left foot. He has developed gangrene of his left foot. showed most disease in the distal vessels and surgical treatment is not an option for these...
code with icd 10 pcs Operative Report AFOPERATIVE DIAS ATIVE DIAGNOSIS: Gangrene of the left foot ERATIVE DIAGNOSIS: Gangrene of the left foot Left below-knee amputation ASTOPERATIVE DIAGA OPERATION: NDICATIONS FOR ONS FOR SURGERY: This is an 86-year-old male who has a history of vasculitis, and peripheral disease, who presents with gangrene of the left foot. He has developed gangrene of his left foot. showed most disease in the distal vessels and surgical treatment is not an option for these...
CODE WITH ICD-10-PCS PLEASE PREOPERATIVE DIAGNOSIS: Generalized lymphadenopathy, probable lymphoma POSTOPERATIVE DIAGNOSIS: Generalized lymphadenopathy, probable lymphoma PROCEDURE: Left suprainguinal lymph node biopsy ANESTHESIA: General endotracheal INDICATIONS FOR OPERATION: This is a 77-year-old female with suspected lymphoma. She has had generalized lymphadenopathy seen on CT and palpable in her inguinal region. She and her family were counseled on the risks and benefits of this procedure. OPERATION: The patient was brought to the operating suite and placed on the table in the...
find the service codes and icd-10-cm code and modifier that goes with the cpt code Week 3: Coding vtabouor. Buck's The 9780321582612//2294/400.00495 CASE 5-32A Operative Report, Breast Mass LOCATION: Outpatient, Hospital was maintained with electrocautery, and then the breast tissue was reapproximated using 2 and 3-0 chromic. The skin was closed using 4-0 Vicryl in a subcuticular fashion. Steri-Strips were applied at the conclusion of the procedure. The patient tolerated the procedure well and was returned to the recovery area...