Chart 410198

This chart has 4 codes. 2 Diagnosis Codes and 2 Procedure codes.

List the Primary Diagnosis below. (JUST list the code so that it auto-grades correctly)

Chart 410198

This chart has 4 codes. 2 Diagnosis Codes and 2 Procedure codes.

List the Secondary Diagnosis below. (JUST list the code so that it auto-grades correctly)

Chart 410198

This chart has 4 codes. 2 Diagnosis Codes and 2 Procedure codes.

List the Primary Procedure Code. (JUST list the code so that it auto-grades correctly)

Do you remember how to use NCCI Edits? If so, you can use them to figure out the Primary Procedure. Usually it's the one that takes the most resources. BUT it should be easy enough to figure out which of the two codes is primary based on the nature of these procedures. Which one is the "main" procedure?

Chart 410198

This chart has 4 codes. 2 Diagnosis Codes and 2 Procedure codes.

List the Secondary Procedure Code. (JUST list the code so that it auto-grades correctly)

SUBJECTIVE:

H&P (View-Only)Division of Plastic & Reconstructive Surgery

is a 49 y.o. female who is being seen for a lesion/mass of the left cheek.She had a cyst at the site many years ago,with either excision or drainage with resulting scar. Recently,she has noticed the scar has enlarged,become itchy and at times drains foul smelling material. She is otherwise healthy.

ASSESSMENT:

Benign skin or soft tissue lesion, most likely inclusion cyst or similar.

PLAN:

Discussed option of excision, with details provided about location, orientation and size of resulting scar. She states she has some anxiety with procedures and would like to have sedation or anesth for the case.

PREOPERATIVE DIAGNOSIS:Soft tissue and skin lesiononthe left cheek measuring 1em indiameter.

POSTOPERATIVE DIAGNOSIS:Soft tissue and skin lesiononthe left cheek measuring 1em indiameter.

OPERATION PERFORMED:Excision of lesion, 1em,from the left lower cheek with layered closure.SURGEON

ASSISTANT SURGEON:None.ANESTHESIOLOGIST:

ASSISTANT ANESTHESIOLOGIST:ANESTHESIA: SPECIMEN:Specimen to pathology.

HISTORY:Thisisa woman we sawinclinic with a history and exam consistent with benign lesion of cystic nature of the leftlowercheek that has been present for many years, slowly enlarging and intermittently draining.She wishedtohave it removed. We discussed excision, placement, and size of a resulting scar. We discussed additional risks and benefits, and after answering all questions, a signed written consent was obtained.

PROCEDURE IN DETAIL:The patient wasmetinPreoperativeHolding. Theoperative sitewas marked. Therewerenonewconcerns.The operativeplanwasreviewed. The patientwas brought to theOperating Room and the fullteam time-outwas performed.The patienthadlowerextremitySCDs placed and turned on, and underwent general anesthesiainthe supine position with abundant padding of her extremities and joints.Nopreoperative antibiotics were given duetothe simple skin nature of this andthelocation oftheface.Thearea was preppedanddrapedIntheusualsterilefashion.A second staged time-out wasperformed.Preoperative markingswereconfirmedandorientedinacurvilinear verticalmanner tocoincidewiththenaturalcrease oftheinferior extension ofthenasolabial crease down towards the chin,also knownasthe marionette lines.An elliptical-type excision was incorporated with the closuretofall within this crease.The area was infiltrated with 5mlof 0.25% Marcaine with epinephrine. After time for a vasoconstrictive effect, the incision was carried down

through the skin into the subcutaneous layer. Sharp dissectionwas performed to envelope any scar- appearing tissue and firm nodular tissue.The lesion wasremoved and sent off the fieldforroutinepathologyexamination.The areawas treated with electrocautery for hemostasis and closedin2layerswith3-0Monocryl and4-0Monocryl, Steri-Stripsasa dressing. This completed theoperation.A layered closure was approximately 1.4em inlength.There werenoknown complications.Estimated blood loss was 5m lor less. I was present and performed the operation. The patient was awakened and takentothe Recovery Roominstable condition.

medication:

0.9 % NaCI infusion Rate: 50 mUhr Freq: CONTINUOUS Route: IV

acetaminophen (TYLENOL) tablet 325-650 mgDose: 325-650 mg Freq: ONCE PRN Route: PO PRN Reason: mild pain

HYDROmorphone HCI PF (DILAUDID) injection 0.5 mg

Dose: 0.5 mg Freq: EVERY 5 MIN PRN Route: IV

ondansetron (ZOFRAN) injection 4 mg

oxyCODONE-acetaminophen (PERCOCET) 5- 325 MG per tablet 5-10 mg