# measurement issues- excision codes



## elenax (Nov 19, 2008)

*Skin expert coders!!...I have coding disagreements...need a second opinion!!!!  Help!!!*
*which of the following coding would apply to the scenario below* 

(1)   11646 + 13132
          14060
          11641 + 13131
          14040

(2) 11642 
        11642
        13132
        14060
        14040

*PREOPERATIVE DIAGNOSIS:* 

Squamous cell carcinoma, right medial cheek. 
Basal cell carcinoma, left lower central eyelid.
Basal cell carcinoma, left medial cheek.
Squamous cell carcinoma, left lateral forehead.
 
*POSTOPERATIVE DIAGNOSIS:*                        Same. 

*PROCEDURE:* 

Excision of squamous cell carcinoma, right medial cheek with complex closure.
Excision of basal cell carcinoma, left lower lid, with advancement flap closure. 
Excision of basal cell, left medial cheek, with complex closure. 
Excision of squamous cell carcinoma, left lateral forehead, with advancement flap. 
*CLINICAL HISTORY:* This 59-year-old male presented with a 7-8 mm squamous cell of the right medial cheek, an 8 mm basal cell of the left central lower lid, a 10 mm basal cell of the left medial cheek, and an 8 mm squamous cell carcinoma of the left lateral forehead. 

*OPERATIVE PROCEDURE & FINDINGS:* After satisfactory intravenous sedation, the face was prepped with Technicare and draped in a sterile fashion. All the lesions were outlined and injected with 0.5% Xylocaine with epinephrine. 
The right cheek was approached first through a 37x13 mm, utilizing 2-3 mm margins around the lesions. Extensive undermining was carried out, and hemostasis obtained with electrocautery. The wounds were then closed with 5-0 Maxon in the deep and dermal layer, and 5-0 nylon in the skin. 

The basal cell on the left central lower lid was then excised in an elliptical incision. A flap was then developed superiorly and inferiorly. A small portion of the orbicularis muscle was resected with the specimen. Hemostasis was obtained with electrocautery. The lower lid skin, as it extended over the infraorbital rim, was then advanced superiorly and anchored with 5-0 Maxon to the deep muscle layer, trying to prevent an ectropion and pull of the lower lid margin. The skin was then approximated with 5-0 nylon after medial and lateral wedges were resected, revealing a 24 mm length curved incision, which measured 8 mm in width. 
A basal cell, just medial to this, on the medial cheek, paranasal region, was excised in a long ellipse with a small bridge of skin between the two incisions. Extensive undermining was accomplished towards the central cheek and over to the alar base. Hemostasis was obtained. The wound edges were advanced,  slightly rotated and secured with 5-0 Maxon in the deep and dermal layer, and 5-0 nylon in the skin. This did produce some additional traction on the lower lid skin, but was not extensive to cause malposition of the lower lid.

The lesion on the left lateral forehead was then excised in a curved ellipse, utilizing 2-3 mm margins. Because of traction on the brow and elevation, an advancement forehead flap from above was then developed and advanced inferiorly. This was secured to the deep subcutaneous tissue as well as to the 
lower lid skin incision. The defect measured 37x12 mm. The medial and lateral wedges of the advancement flap were then resected, producing a 43 mm length incision. 

Antibiotic ointment and sterile dressings were applied.


----------



## BFAITHFUL (Nov 20, 2008)

These are the codes I came up with,  

11642
11641
13132
14040
14060

op report states there was 7-8mm = .7cm -.8cm lesion of right med. cheek  with 2-3mm = .2cm-.3cm margins = 11642
10mm of left medial cheek = 1.0cm no mention of margins? so although there were probably margins taken you're forced to code based on this 1.0cm = 11641

as far as the repairs, according to CPT guidelines, you are to sum the lengths of repairs for each group of anatomic sites

this op report could be clearer though, for example length of the complex repairs? margin sizes?


----------



## elenax (Nov 21, 2008)

Thank you very much for your help!... 

Would you mind if I inquiry you in the future??...if yes please send me your aapc email address...thanks,


----------

