AUDIT REPORT T14.1 OPERATIVE REPORT, RESECTION

Essay

AUDIT REPORT T14.1 OPERATIVE REPORT, RESECTION
HEMANGIOMA
This anesthesia service is being provided for a 78-year old patient. Anesthesia by: MDA and CRNA. Anesthesiologist was medically directing 3 concurrent cases. The physical status is 2.
CLINICAL NOTE: This is a 89-year-old man who presents with a 2-month history of pain on the dorsal penile area. Ultrasound showed this to be a solid mass. No flow was seen within it. It is thought to possibly be a sarcoma. It is a soft mass, and it may be vascular. Resection will be done to determine what we are dealing with.
OPERATIVE NOTE: The patient was placed under general anesthesia via endotracheal tube. The patient was prepped and draped in the supine position. An incision was made on the dorsal side of the penile shaft, overlying the mass. Just below the skin, a large vein was encountered. Bleeding was controlled with ligation using 3-0 chromic ligatures. The mass was seen and was approximately 9 cm long. Under closer inspection this was noted to be a hemangioma coming from the superficial veins from Buck's fascia. Care and mobilization were taken, and all perforating vessels were individually ligated with chromic ligature. Photographs were taken during the procedure showing the extreme vascularity of the lesion. Frozen section was taken, and this showed no malignancy present. After the mass was resected it left a large cavity in the base of the patient's penile shaft. The subcutaneous tissues were closed with 4-0 chromic, and the skin was closed with subcuticular Dexon. A compression dressing was applied. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
PATHOLOGY REPORT LATER INDICATED: Benign hemangioma
One of the following modifiers is incorrectly reported for this case. Indicate the modifier that is incorrect.
T14.1:
PHYSICIAN CODE: 00920-QY-P2, 99100_______________
CRNA CODE: 00920-QX-P2__________________________
INCORRECT MODIFIER:___________________________