Home » Can you code this » Medical coding Sample Operative Report

Medical coding Sample Operative Report

PREOPERATIVE DIAGNOSIS: Atypical skin lesions.

POSTOPERATIVE DIAGNOSIS: Atypical skin lesions

ANESTHESIA: Local 1% lidocaine, 0.5% Marcaine and bicarbonate.


1. It is a 1 cm right upper arm lesion, a). A 3 cm x 1 cm excision.

2. 1.2 cm left supraclavicular lesion a). A 4 cm x 1.5 cm excision.

3. Multiple skin tag excisions, left axilla and right neck.

4. A left leg skin neoplasm measuring 4 x 5 cm.

Medical coding sample operative report

Get FREE CEUs here!

BRIEF HISTORY: The patient is a 53-year-old gentleman with a history of basal cell carcinoma as well as melanoma, who presents with atypical skin lesion. Excision was recommended and consent was obtained. He was prepared for the minor room operative procedure.

DESCRIPTION OF THE PROCEDURE: After proper identification in holding, the lesions were confirmed with the patient and he was taken to the operating room and placed in a supine position. His right upper arm was prepped and draped in a sterile fashion. Local lidocaine and Marcaine was instilled around the atypical lesion and this was excised with good margins. Hemostasis was excellent and controlled by electrocautery and two-layered closure was performed with interrupted Vicryl and interrupted running nylon. Dry dressing was applied. I then turned my attention towards the left supraclavicular lesion. A fresh blade was utilized for excision after instilling local lidocaine and marcaine. This was excised down to fat and electrocautery was utilized to create hemostasis. Skin was extensively undermined and then two-layered closure was performed with interrupted Vicryl and interrupted running nylon. Dry dressing was applied. He had multiple skin tags in left axilla and right neck. These were excised and desiccated without difficulty. Attention was directed to the left leg. An elliptical incision was made around the lesion and it was excised with no difficulty. Closure seems to be necessary with advancement flap due to the size of excision. Bilateral flaps were advanced and rotated into position covering the excisional defect. Skin was closed with interrupted Vicryl suture. He tolerated the procedure well. Needle and sponge counts were correct and he is transferred to recovery in stable condition.

DMCA.com Protection Status CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association