This Outpatient Surgery Cases, the coding we need is Diagnoses and Procedures. And to Make sure you list the Primary diagnosis FIRST and the primary procedure FIRST.

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.

C Co om m p l a i n t Patient presents with

New Patient

consult for facial cyst

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 lesion on the left cheek measuring 1 em in diameter.

POSTOPERATIVE DIAGNOSIS: Soft tissue and skin lesion on the left cheek measuring 1 em in diameter.

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

ASSISTANT SURGEON: None. ANESTHESIOLOGIST:

ASSISTANT ANESTHESIOLOGIST: ANESTHESIA: SPECIMEN: Specimen to pathology.

HISTORY: This is a woman we saw in clinic with a history and exam consistent with benign lesion of cystic nature of the left lower cheek that has been present for many years, slowly enlarging and intermittently draining. She wished to have 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 was met in Preoperative Holding. The operative site was marked. There were no new concerns. The operative plan was reviewed. The patient was brought to the Operating Room and the full team time-out was performed. The patient had lower extremity SCDs placed and turned on, and underwent general anesthesia in the supine position with abundant padding of her extremities and joints. No preoperative antibiotics were given due to the simple skin nature of this and the location of the face. The area was prepped and draped In the usual sterile fashion. A second staged time-out was performed. Preoperative markings were confirmed and oriented in acurvilinear vertical manner to coincide with the natural crease of the inferior extension of the nasolabial crease down towards the chin, also known as the marionette lines. An elliptical-type excision was incorporated with the closure to fall within this crease. The area was infiltrated with 5 ml of 0.25% Marcaine with epinephrine. After time for a vasoconstrictive effect, the incision was carried down

through the skin into the subcutaneous layer. Sharp dissection was performed to envelope any scar- appearing tissue and firm nodular tissue . The lesion was rem oved and sent off the fie ld fo r routine pathology examination. The area was treated with electrocautery for hemostasis and closed in 2 layers with 3-0 Monocryl and 4-0 Monocryl, Steri-Strips as a dressing. This completed the operation. A layered closure was approximately 1.4 em in length. There were no known complications. Estimated blood loss was 5 m l or less. I was present and performed the operation. The patient was awakened and taken to the Recovery Room in stable condition.

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CLINICALHISTORY:49year-oldAsianfemalewithpainfullesiononleftface.DIAGNOSIS:

A. Skin and subcutaneous, left cheek lesion

EPIDERMAL CYST

G ROSS DESCRIPTION:Received the following specimen(s) in the Department of Pathology, labeled with the patient's name and hospital #

A. Skin and subcutaneous, left cheek lesion

A. The specimen is received in formalin, designated "Skin and subcutaneous, cheek lesion" and consists of an unoriented, elliptical excision of beige, slightly raised, granular skin and pink to yellow subcutaneous tissue. The specimen is 1.5 cm long by 0.5 cm wide and is excised to a depth of 1.0 cm. The incisional margins are inked blue. The specimen is serially sectioned, revealing a 0.4 cm subcutaneous cystic focus, containing yellow-tan debris. The cut surfaces of the subcutaneous tissue are otherwise fibrotic and gray-beige. The specimen is submitted entirely, as follows:

A1 Tips

A2 Remaining specimen, submitted entirely (5/29/2014 GRD/cdl)

MICROSCOPIC DESCRIPTION:

A. Within the dermis there is a cyst lined with stratified squamous epithelium with epidermal keratinization and

"I, or my qualified designee, performed the gross examination. I have personally reviewed the gross description and performed a microscopic examination on all referenced material. I have personally issued this report on the basis of the gross and microscopic findings."

Resident/Prosector/Pathologist:

ICD9 Codes: 706.2 Diagnostic/Retrieval Codes: (FDD/KFS)

medication are 0.9 % NaCI infusion Rate: 50 mUhr Freq: CONTINUOUS Route: IV Start: 0730 End:1459, acetaminophen (TYLENOL) tablet 325-650 mgDose: 325-650 mg Freq: ONCE PRN Route: PO PRN Reason: mild pain Start:0901 End: 1459

-AdminInstructions: Maximum acetaminophen dose from all sourcesis4

grams or 75 mg/kg (whichever is less) per 24 hour period. HYDROmorphone HCI PF (DILAUDID) injection 0.5 mg

Dose: 0.5 mg Freq: EVERY 5 MIN PRN Route: IV PRN Reason: other PRN Comment: For severe or breakthrough pain

Start:0901 End:1459

ondansetron (ZOFRAN) injection 4 mg

Dose: 4 mg Freq: PRN Route: IV PRN Reason: nausea

Start:0901 End: 1459 oxyCODONE-acetaminophen (PERCOCET) 5- 325 MG per tablet 5-10 mg, Maximum dose of acetaminophen is 4000 mg from all sources in 24 hours.