# New to derm, can someone please tell me how they would code TIA



## MELJNBBRB (Feb 4, 2014)

Pre-procedure Diagnoses 
  1. Lentigo maligna [232.9] 
  2. Squamous cell carcinoma in situ of skin of temple region [232.3] 
  3. Neoplasm of uncertain behavior of skin [238.2] 


    Skin excision
Consent: Written consent obtained.
Time out: time out called, correct patient, site and side verified, correct procedure and correct patient position.
Patient tolerance: Patient tolerated the procedure well with no immediate complications.
Procedure Note: The patient has no pacemaker nor defibrillator and denies a need for preoperative antibiotics.  He indicates understanding of risks which include bleeding, infection, scar, recurrence and need for further treatment should the margin be positive.

He is noted to have a 2.4 x 1.5 cm dark and light brown ill-defined patch on the central crown of the scalp with central hypopigmentation. He believes prior biopsies have been performed here, but it has been years. I order to rule out melanoma versus large seborrheic keratosis, a biopsy by shave technique was performed to the lesion.

PROCEDURES:
Excisions with layered closure.

DIAGNOSES:
1. Lentigo maligna.
2. Squamous cell carcinoma in situ with follicular extension.
3. Moderately dysplastic nevus.

SITES:
1. Left central cheek.
2. Left temple.
3. Left preauricular cheek.

EXCISED DIAMETERS:
1.         2.4 cm
2.         1.2 cm
3.         1.3 cm

EXCISION LENGTHS:
1.         4.3 cm
2.         2.4 cm
3.         3.2 cm

After informed consent, the patient was placed in position and was prepped,
draped and anesthetized in the usual fashion with 1% lidocaine and
epinephrine 1:100,000 buffered with sodium bicarbonate. A surgical timeout was
performed. Elliptical excisionswere made through the skin down to the
subcutaneous tissue with 0.5 cm clinically tumor free margins for the left central cheek site and 0.3 cm margins
for the left temple and left preauricular cheek sites. The wound edges were undermined extensively to allow 
primary closure and minimize distortion of facial structure. Hemostasis was obtained with electrocoagulation.

Due to the wound size, the wound edges were closed in a layered fashion
with 4-0 polysorb and 5-0 subcutaneous sutures (left central cheek), 5-0 polysorb subcutaneous sutures (left temple and left preauricular cheek)
and 5-0 Surgipro skin sutures.

ESTIMATED BLOOD LOSS:
Minimal.

COMPLICATIONS:
None.

WOUND CARE:
Routine.

The specimen was sent to the Department of Pathology for review, and the
report is pending.

ANTISEPTIC:
Alcohol/chlorhexidine.

ANESTHETIC:
Lidocaine 1% with epinephrine 1:100,000 buffered with sodium bicarbonate.

WOUND CLASS:
Type I.




Path report :

BRIEF CLINICAL HISTORY
1 - lentigo maligna, left central cheek, excision, 2 - moderately
dysplastic nevus, left preauricular cheek, excision, 3 - squamous cell
carcinoma in-situ, left temple, excision, 4 - SK vs AK vs dysplastic
nevus, central crown of scalp, shave biopsy.


GROSS:
Specimen #1 labeled as left central cheek, is a 3.2 x 1.6 x 0.8 cm
ellipse of a tan skin with a central 1.0 x 0.5 cm tan area of depression
and a suture designating 12 o'clock margin.  Ink code:  black 12
o'clock, red 6 o'clock.  Sectioned and entirely submitted:  1A-1B - 3
o'clock, 1C-1D - 9 o'clock.

Specimen #2 labeled left preauricular cheek is a 2.2 x 1.2 x 0.5 cm
ellipse of tan skin, with an apical suture designating 12 o'clock.  Ink
code:  black 9 o'clock, red 3 o'clock.  Sectioned and entirely
submitted:  2A - 12 o'clock, 2B - 6 o'clock.

Specimen #3 labeled left temple is a 1.5 x 0.9 x 0.4 cm ellipse of tan
skin with a central 0.5 x 0.3 cm tan area of erosion, and a suture
designating 12 o'clock.  Ink code:  Black 9 o'clock, red 3 o'clock.
Sectioned and entirely submitted in 3A - 12 o'clock, 3B - 6 o'clock.

Specimen #4 labeled central crown scalp is a 1.2 x 0.7 cm shave of tan
skin with a 0.2 cm ?? brown apical macule, a 0.4 x 0.2 cm brown apical
macule.  Sectioned and entirely submitted in 4A.

MA/rsp/MPF

MICROSCOPIC DIAGNOSIS:
Skin, left central cheek, excision:  Malignant Melanoma In-Situ, Lentigo
Maligna type,
       residual, completely excised.

Skin, left preauricular cheek, excision:  Previous biopsy site changes.

       No residual melanocytic proliferation identified.



Skin, left temple, excision:  Previous biopsy site changes.

       No residual squamous cell carcinoma in-situ identified.

Skin, central crown of scalp, shave biopsy:  Seborrheic keratosis.


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## CatchTheWind (Feb 7, 2014)

*Please clarify*

Your question isn't clear; what do you mean "how they would code TIA"?  What does TIA mean in this context?

Also, not sure what your doctor means by "excised diameter" and then "excision length" - does he mean "lesion diameter" and then "excision length"?


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## mitchellde (Feb 7, 2014)

TIA is an abbreviation for thanks in advance.
The excised diameter appears to be the lesion size and the excision length appears to be the excision size with margins.
Your dx codes per path are the melanoma, skin disorder, and seborrehic keratosis.
The excision codes will be one malignant excision and 2 benign excision codes
Add the lengths of the repairs together and code  one intermediate repair code.
I feel it is important for you to look the codes up for the correct numbers.  You should be able to do this once you have the logic.


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