The professional CPT codes and ICD-10
What is the professional CPT codes and ICD-10 For this report?
LOCATION: Outpatient, Hospital PATIENT: Madelyn Michaels SURGEON: Mohomad Almaz. MD PREOPERATIVE DIAGNOSIS: Mass, left prepatellar bursa. Indications: Madelyn is a housekeeper at a hospital and complains of left knee pain due to a small mass in the prepatellar bursa. She requested surgical intervention for this condition and presents today for same. I have discussed risks, and potential problems with the surgery and post operative care and she wishes to proceed at this time. POSTOPERATIV E DIAGNOSIS: Same. PROCEDURES PERFORMED: Excision of mass, left prepatellar bursa. ANESTHESIA: Local infiltration with 1% Xylocaine. supplemented with IV sedation. PROCEDURE: The patient was placed in the supine position on the operating room table. She pointed out the mass on the anterior aspect of her left knee, which was a very small mass. perhaps 2 or 3 mm in diameter. This bothers her when she kneels on her left knee. and she wanted it removed. We therefore marked it with a marking pen since it was not a large mass but was still nevertheless fairly easily palpable. We then prepped her left knee with Betadine and draped it in a sterile fashion. She was given IV sedation. We then infiltrated the area around the mass with 1% Xylocaine. Once adequate anesthesia had been achieved, we exsanguinated the left leg with Esmarch bandage and inflated a tourniquet to 225 mm Hg. The total toumiquet time was about 6 minutes. We created an incision in a longitudinal fashion directly over this mass and carried it down through the subcutaneous tissue. We Very quickly found this mass. which was perhaps half the size ofa pea (1.2 cm). It was fairly firm. and we sent it to pathology. It appears to be part of the left prepatellar bursa. We then excised some of the adjacent bursa] tissue. We found this was located directly over the left patella and the patella was very visible underneath this mass. We then probed the area. looking for any other masses. We then thoroughly irrigated the area and closed the subcutaneous tissue with 2-0 Vicryl and the skin with 3—0 nylon suture. Pressure was applied to this area, and the tourniquet was released after 6 minutes of tourniquet time. We then applied a 4 x 4 dressing and an Ace wrap over this. She was then awakened and taken from the operating room in good condition. breathing spontaneously. The final Sponge and needle counts were correct. She tolerated this procedure very well. ‘ Pathology Report Later Indicated: Benign neoplasm of left prepatellar bursa.
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