To determine the CPT code and ICD-9-CM code, we need to analyze the information provided in the operative report.
CPT codes are used to identify specific medical procedures, while ICD-9-CM codes are used to classify diagnoses.
Looking at the operative report, here is how we can determine the appropriate codes:
1. CPT Code: In this case, the operative procedure performed is the "Excision of left flank soft tissue mass with layered closure measuring 4 cm, with margins, prior to excision". To find the corresponding CPT code, we can search for the relevant procedure in the CPT code manual. Based on the description, the most appropriate CPT code would be 11402 - Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm. This code indicates that the excision was performed on a benign lesion on the trunk.
2. ICD-9-CM Code: The preoperative and postoperative diagnosis is "Left flank soft tissue mass". To determine the ICD-9-CM code, we can search for the diagnosis in the ICD-9-CM code manual. The most relevant code would be 238.2 - Neoplasm of uncertain behavior of connective and other soft tissue. This code indicates a soft tissue mass with uncertain behavior.
Therefore, the CPT code for this operative report is 11402, and the ICD-9-CM code is 238.2.