TWO DIAGNOSIS CODES PLEASE!!!! Code this operative report as if you work in the
ID: 243735 • Letter: T
Question
TWO DIAGNOSIS CODES PLEASE!!!!
Code this operative report as if you work in the hospital.
Coding Hint: There are two diagnosis codes, two CPT codes, and one modifier associated with this report.
Operative Report
PREOPERATIVE DIAGNOSIS: Painful left gynecomastia and umbilical hernia.
POSTOPERATIVE DIAGNOSIS: Painful left gynecomastia and umbilical hernia.
PROCEDURE PERFORMED: Left subcutaneous mastectomy and repair of umbilical hernia.
FINDINGS: This 77-year-old male has an enlarged, painful left breast which was sensitive to even his clothes touching it. There was a 4 cm diameter umbilical hernia.
PROCEDURE: After satisfactory general anesthesia, the abdomen and left chest was sterilely prepared and draped.
A transverse incision was made below the umbilical skin. The subcutaneous tissue was opening and then using sharp dissection, the sac was dissected from the overlying skin around the entire circumference of the hernia opening. The fascia at the edge of the defect was then opened down to the peritoneum, which was left intact. No bleeding was encountered at this point. The sac was then inverted into the preperitoneal space and the fascia was closed using interrupted sutures of 0 Tycron, which made for a secure fascial closure.
Next, the subcutaneous tissue was thoroughly irrigated. The skin was then tacked to the fascia using interrupted sutures of 3-0 plain catgut. The subcutaneous tissue was then closed using interrupted suture of 3-0 plain catgut, and the skin closed using a subcuticular stitch of 4-0 Vicryl. Steri-Strips were applied. ____Op-Site dressing was applied.
Attention was then turned to the left breast where a circumareolar incision was made down to the subcutaneous tissue. Then, using blunt and sharp dissection, the subcutaneous tissue was dissected from the overlying skin around the entire stump of the nipple. The nipple ducts were then severed and then this was grasped with an Allis clamp.
Next, the breast tissue was excised from the subcutaneous tissue using the cautery. Bleeding was minimal and was controlled with the cautery.
After this, the wound was thoroughly irrigated. A PLS drain was placed into the wound to exit through the skin and was sutured into place using 3-0 black silk. The subcutaneous tissue was then closed using interrupted sutures of 3-0 plain catgut and the skin closed using subcuticular interrupted stitch of 3-0 plain catgut.
Steri-Strips were applied, 4 x 4s and Op-Site dressing.
The blood loss for the entire procedure was estimated at perhaps 10cc. The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.
Explanation / Answer
Diagnosis code for
Left gynecomastia - N62
Umbilical Hernia - K42
Code for the procedures
Left subcutaneous mastectomy - Z42
Repair of Umbilical Hernia - S2076
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