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  1. Kathy Posted 6 Year(s) agoRelated Topics

    How would this be coded? the path report stated "rheumatoid nodule"

    PREOPERATIVE DIAGNOSIS: Rheumatoid nodules right thumb, index and long
    finger and left long finger.

    1. Removal of masses (rheumatoid nodules from the right index finger, right
    long finger and right thumb).
    2. Removal of rheumatoid nodule from the left long finger.

    ANESTHESIA: Local with sedation.

    INDICATIONS FOR PROCEDURE: 63-year-old male with tender nodules on the
    working surfaces of the above mentioned fingers.

    DESCRIPTION OF PROCEDURE: This 63-year-old male was brought to the
    operating room where he was placed supine on the operating room table and
    had induction of intravenous sedation. A pneumatic tourniquet was affixed
    to the proximal aspect of the right upper extremity and the left forearm.
    Both hands were then prepped and draped in the usual sterile fashion.
    Right upper extremity was elevated and exsanguinated, and the tourniquet
    was inflated to 250 mmHg. An incision was made over the nodules of the
    index finger which were on the dorsal radial aspect. Two well encapsulated
    nodules were identified that originated beneath the fascial surface and
    were connected to the PIP joint. The dorsal cutaneous nerve was wrapped
    around the nodules and dissected off the nodules and the nodules were
    excised and submitted for pathologic examination.

    A second incision was made over the nodule of the middle finger and
    similarly this was dissected off surrounding deep tissues and submitted for
    pathologic examination and had the gross appearance of a rheumatoid nodule.
    All surgery was performed under loop magnification and cutaneous nerves
    were preserved for a possible, and the digital nerve and artery were
    identified and protected.

    Third incision was made over the mass at the thumb and similarly it was
    dissected off the flexor tendon sheath and submitted for pathologic
    examination. Tourniquet was deflated at the right upper extremity. There
    was no excessive bleeding. Wounds were irrigated and hemostasis was
    obtained via gentle pressure and electrocautery. Marcaine with epinephrine
    was used just at the skin edges, and plain Marcaine was used in the deep
    tissues. Wounds were closed using nylon suture.

    Attention was then paid to the left hand which had been prepped and draped.
    Left arm tourniquet was inflated. Incision was made over the mass at the
    left long finger and dissection was performed under magnification and the
    nodule was dissected off nerves and tendon structures and submitted for
    pathologic examination. Left hand tourniquet was deflated. Wound was
    irrigated. There was no excessive bleeding. Hemostasis was obtained via
    gentle pressure and electrocautery, and skin was closed with nylon. Bulky
    dressing was applied to both hands. The patient tolerated the procedure
    well and was transferred from the operating room to recovery room in stable

  2. SuperCoder Posted 6 Year(s) ago


About this Question

  • Posted by 27904 Kathy, 6 Year(s) ago. There are 2 posts. The latest reply is from SuperCoder.