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Mass excision; documentation for skin, subcutaneous or subfascial level

Camille Posted Sat 02nd of November, 2019 17:11:58 PM
Qu#1) I do not find enough documentation in this excerpt of the Op Note to indicate whether these flank mass excisions were done at the level of Integumentary, Subcutaneous or Subfascial. Do you agree this is not enough information to correctly code these 3 flank mass excisions? "Three right-sided flank masses were excised 2, 3 and 4cm. The 4cm mass along the posterior axillary interface. Separate skin incisions were made for these and skin flaps were raised and they were dissected free using a combination of sharp dissection and blunt dissection. These were all closed with 3-0 Vicryl for the deep layer, followed by 4-0 Monocryl." Qu#2) I do not find enough documentation in this excerpt of the Op Note to indicate whether this forearm mass was done at the level of Integumentary, Subcutaneous or Subfascial. Do you agree this is not enough information to correctly code the forearm mass excision? "The forearm was preared and draped. A longitudinal skin incision was made and the superficial 1 cm right forearm mass was excised and sent to pathology. This was closed using 3-0 Vicryl suture, followed by 4-0 Monocryl."
SuperCoder Answered Mon 04th of November, 2019 06:41:45 AM
Hi Camille,
 
Thanks for your question.
 

In both the cases, the documentation is really not sufficient to code this. Please either collect the pathology report to confirm or ask the doctor’s clinic to update the information regarding depth of all the masses (i.e. from which level these masses have been excised i.e. integumentary, subcutaneous or subfascial) so that it can be coded correctly.

 
Please feel free to write if you have any question.
 
Thanks.

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