Case
-AUDIT REPORT T10.1 OPERATIVE REPORT, RESECTION
LOCATION: Outpatient, Hospital
PATIENT: Donald Styel
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Left hydrocele, left scrotal mass
PATIENT: Left hydrocele
PROCEDURE PERFORMED: Resection of hydrocele sac, left testicular cord, left scrotum, and resection of left paratesticular mass.
CLINICAL NOTE: This is a 78-year-old gentleman who has developed a hydrocele and has a left scrotal mass. We have discussed different options, and he has decided he would like this surgically taken care of. The patient has been marked earlier for surgery.
OPERATIVE NOTE: The patient was given a general endotracheal anesthetic, prepped, and draped in the supine position. A midline scrotal incision was made and the testis delivered. Two hydroceles were identified, one of the testis and one of the cord. The hydrocele of the cord was resected. Hemostasis was achieved with electrocautery. The hydrocele sac of the scrotum was also opened and resected. Once opening this, there was a very dark 1.5-cm lesion separate from the epididymis and testis in the region of the testicular cord. This was mobilized, isolated, and resected intact. It did not appear to have a blood supply or be in association with any of the cord or testicular structures. This was sent separately for pathologic identification. Once hemostasis was achieved, the testis was returned to the scrotum. A 1/4-inch Penrose drain was left through a separate stab wound and sutured to the skin with 2-0 Prolene. The scrotum was closed in two layers with a 3-0 chromic. Dressings applied. Scrotal support applied. The patient was transferred to the recovery room in good condition.
10.1:
SERVICE CODE(S): 55040, 55500-51_________
ICD-10-CM DX CODE(S): N43.3, N43.3______
INCORRECT/MISSING CODE(S): ________________________________________

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The Answer of Case
-AUDIT REPORT T10.1 OPERATIVE REPORT, RESECTION
LOCATION: Outpatient, Hospital
PATIENT: Donald Styel
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Left hydrocele, left scrotal mass
PATIENT: Left hydrocele
PROCEDURE PERFORMED: Resection of hydrocele sac, left testicular cord, left scrotum, and resection of left paratesticular mass.
CLINICAL NOTE: This is a 78-year-old gentleman who has developed a hydrocele and has a left scrotal mass. We have discussed different options, and he has decided he would like this surgically taken care of. The patient has been marked earlier for surgery.
OPERATIVE NOTE: The patient was given a general endotracheal anesthetic, prepped, and draped in the supine position. A midline scrotal incision was made and the testis delivered. Two hydroceles were identified, one of the testis and one of the cord. The hydrocele of the cord was resected. Hemostasis was achieved with electrocautery. The hydrocele sac of the scrotum was also opened and resected. Once opening this, there was a very dark 1.5-cm lesion separate from the epididymis and testis in the region of the testicular cord. This was mobilized, isolated, and resected intact. It did not appear to have a blood supply or be in association with any of the cord or testicular structures. This was sent separately for pathologic identification. Once hemostasis was achieved, the testis was returned to the scrotum. A 1/4-inch Penrose drain was left through a separate stab wound and sutured to the skin with 2-0 Prolene. The scrotum was closed in two layers with a 3-0 chromic. Dressings applied. Scrotal support applied. The patient was transferred to the recovery room in good condition.
10.1:
SERVICE CODE(S): 55040, 55500-51_________
ICD-10-CM DX CODE(S): N43.3, N43.3______
INCORRECT/MISSING CODE(S): ________________________________________

Case -AUDIT REPORT T10.1 OPERATIVE REPORT, RESECTION