# Coding the approach in ICD-10-PCS



## cmmfeyen (Nov 20, 2014)

How do I code the approach on this biopsy: 
PROCEDURE:  The patient was prepped and draped sterilely in the lithotomy position.  The lesions were at the base of the labia majora bilaterally, extending onto the perineal body.  An elliptical incision was made starting about halfway up on the labia minora on the left, bringing it around on the perineal body on the outside and around the hymenal ring on the inside, up to about halfway up the labia on the opposite side.  The Bovie cautery was then used to undermine the subcutaneous tissues and the specimen was marked at 12 o?clock and frozen section biopsy submitted to pathology, proven to be dysplasia.  I obtained frozen section biopsies from 2, 4 and 6 o?clock, and all were reported as negative for dysplasia.  

The area was closed with a running, locking 2-0 Vicryl, starting in the midline and working up the right labia and then starting in the midline and working up the left labia. Gentamicin ointment was applied to the incision sites, and the patient was then awakened and sent to recovery in stable condition.

I was thinking that the approach was external, but someone else is saying open because the Bovie cautery is creating a deeper cut.  Help!!!!


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