# neep help coding op report derm.



## ortega831

Hi 

I need help coding and applying the correct modifiers on this sx and needing  a coders opinion 

I'm new to this specialty 

Thank you ahead of time for your help 

Operation:
1.Excision of basal cell carcinoma w/ multiple frozen sections until margine clear.
2.Internal septal flap reconst.of nasal lining.
3.septal cartilage graft reconstruction of nasal defect 
4.paramedian forhead flap reconst. of nasal skin defect
5.nasolabial flap reconstruction of cheek defect
6.split thickness skin graft from the rt side to cover defect of teh forehead

CPT
15574
15100 51 59
14040 59
20912 59


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## mitchellde

Is there any way you can post the op report?  It would be better for analysis.  Just a question... Is it possible this was a Mohs procedure followed by nasal reconstruction?   It looks like that may be given the list of procedures.  I know you said you were new to this specialty, and I do not want to be too critical, however I do not think you have the procedure codes at all correct.  If you can post the note I could be of more assistance on the correct procedure codes.


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## ortega831

*The following is the Description of Procedure/Findings from the OP Report*

The Patient was identified in the holding are and the case reviewed again with him in detail. The patient was taken back to the operating room, transferred to the operating table and placed in the supine position. Once adequate anesthetic induction was achieved, he was endotracheally intubated with an oral ray tube which was secured to the midline of the lower lip. The patient was the turned 90 degrees to the anesthesiologist.

The face and head were then prepped and drapped in the usual sterile fashion. The nose was initially injected with approximately 10cc of 1% lidocaine with 
1:100,000 epinephrine along the septum and neuro patties soaked in local were also placed to provide topical decongestion. The nasal skin was also injected with an additional 10cc of 1% lidocaine with 1:100,000 epinephrine. Beginning with a #15 blade scalpel, excisions were made at the periphery of the tumor and marked, discussed with the pathologist and sent for frozen section. The initial defect started at 2.5 x 2.5 cm and ultimately ended up being close to 6 x 6 cm. Margins were finally freed at the last specimen taken.

With that, attention was turned to creating the internal nasal septal flap.
A bucket-handle flap was created and rotated anteriorly to provide internal lining. On the left side of the septum, care was taken using a hemitransfixion approach to isolate cartilage. The bony cartilaginous junction was separated with a caudal elevator and the segment of cartilage excised sharply with a #15 blade scalpal, maintaining the integrity of both flaps of septal mucosa. A 1 x 1 cm L-strut was left to support the nose. Cartilage was then placed in saline.

Cartilage grafts were then cut and fashioned to bolster the lateral nasal wall essentially replacing a portion of the defect from the opening of the pyriform aperture to where the lower lareral cartilages would be. In addition, this segment of cartilage was approximately 1.5 x 2 cm. This was followed by cutting another graft essentially to support and bolster the alar rim. This measured approximately 6 mm in width, 1 mm in height, and almost 2 cm in length. This was placed in position by dissecting a small pocket along the remnant ala laterally. The grafts were secured with a series of 5-0 Biosyn sutures. The medial aspect of the alar graft was secured to what remained of the medial crus and tip protecting point of the right lower lateral cartilage.

Next, marks were made for desing of the nasolabial advancement flap. Once this was marked, it was injected with 10 cc of 1% lidocaine with 1:100,000 epinophrine. A #15 blade scalpel was used to cut along the nasolabial fold, leaving the alar base of the nose alone and extending approximately 2 cm below the right lower eyelid. The flap was undermined sharply with short sharp scissors and then advanced into position and secured with 4-0 monocryl deep and 5-0 nylon, closing the nasolabial fold, and 6-0 prolene in the lower eyelid skin.

The septal mucosal flap was secured and tacked down to the cartilage with a series of 5-0 chromic mattress sutures. A small segment of AlloDerm was cut and sutured to the contralateral septal mucosa to provide additional lining and to promote mucosalization. An additional small piece was sewn to the larger cartilage graft to provide again aide with mucosalization internally.

Next, the paramedian forehead flap was designed based on the left supratrochlear neurovascular bundle. This was marked and measured and then outlined on the forehead. The forehead was then injected with approximately 20 cc of 0.5% licocaine with 1:200,000 epinephrine. A #15 blade scalpel was then used to make the incision and a subgaleal plane of dissection was created, presserving the periosteum to within approximately 1 cm of the brow. At approximately 1 cm above the brow a subperiosteal plane was then created and dissection along  the bone to the supratrochlear foramen was performed. The flap was then able to be rotated into position. It was wrapped with saline gauze and attention turned to closure of the forehead.

Wide undermining was performed in the subgaleal plane and attempts to close the forehead were difficult. The patient had very tight and thin skin. At that point, it was decided to use a split-thickness skin graft, which would be isolated from the right thigh.

The right thigh was then prepped and drapped in the usual sterile fashion. The forehead wound was closed with 3-0 Monocryl deep and a 5-0 nylon in the skin, and a defect measuring approximately 3 x 4 cm was remaining. A split-thickness skin graft of 5 x 5 cm was cut with the thickness of 0.017 mm. This was isolated with Padgett dermatome and the graft was then pie-crusted with a #15 blade scalpel. Saline-soaked gauze was placed over the donor site. The skin graft was then cut and fashioned to fit over the defect in the frontal scalp. It was secured with a running 5-0 chromic suture and then a bolster of cotton balls coated in bacitracin ointment and Xeroform was placed over it and secured with a series of 3-0 silk sutures. The donor site was then dressed with Mastisol. Tegaderm, and urtimately with Kerlix and Ace wrap.

Attention was then returned to the nose. The nasal flap was not thinned because it was quite thin already. Blood flow appeared to be adequate. The flap was then closed in two layers with 5-0 Monocryl or Biosyn deep, followed by a series of running 5-0 nylon in the skin. At the level of the alar skin mucosal junction, 5-0 chromic was used to apporximate the lining flap with the edge of the skin flap internally. Oozing was controlled with light pressured. The flap was visualized to be viable and good capillary refill was noted. A strip of  Xeroform was placed under the pedicle of the flap and the wounds were then cleaned with saline and dried. Bacitracin ointment was applied liberally. Two Merocel nasal packs with suture were coated in ointment and placed  on either side of the nose to help with stenting and oozing. They were tied in front of the  columella in several surgeon's knots. They were infiltrated with approximately 1 cc of the local anesthesia and swelled accordingly.

Of note, tarsorrhaphy sutures had been placed at the onset of the case and these were now removed. The patient was returned to his original position in the operating room. A light Kerlix dressing was placed on the forehead and a drip pad placed as well. The patient was then awakened from general anesthesia, and he was transferred to the PACU in a stable condition.


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## mitchellde

17311 mohs excision
30630 septal flap reconstruction
30520 septal cartilage graft reconstruction
20912 cartilage harvesting
15731 59 paramedial forehead flap
15120 59 split-thickness skin graft
14060 59 nasolabial advancement flap
These are the codes I would use, I have no way right now to check for bundleing but I do not think there will be a problem.  The Mohs documentation could have been better and there may have been more codes but barring that it is pretty straitforward.


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## ortega831

Thank you so much!!!!!!!!!!!!!!


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## LCRUZ515

Coding for mohs surgery (17311) is not the appropriate code for this excision. This code is only used when the physician is acting as the pathologist. In this case he is not since he or she states that they discussed with the pathologist.


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## mitchellde

I have never heard that the surgeon had to be the one doing the path only that microscopic evaluation is performed for pathologic results.  Which is documented as having been done.  I have checked every where and nowhere does it state that this must be the same doctor.  We did these all the time in the cancer center and always used these codes, rarely was the surgeon performing the path but when he did we used the path code as well.   I agree that the documentation is not the best it can be, however from what is there this does appear to be a MOHs procedure.


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## RebeccaWoodward*

Excerpt from CPT Assistant......

Mohs micrographic surgery is a technique for the removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. It is a combination of surgical excision and surgical pathology that requires a single physician to act in two integrated but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports the services separately, these codes should not be reported. The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic examination. Thus a tissue block in Mohs surgery is defined as an individual tissue piece embedded in a mounting medium for sectioning.


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## mitchellde

Thank You Rebecca I looked every where.  But we really did use these codes, I wonder if that has changed over the years then.  The problem now with this report is what code would you use for the excision, or since the defect is cover with reconstruction then the excision is inclusive.  Now it makes you wonder about the documentation.


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## Kelly_Josephine

Thank you from me too! I love the search function here - you covered my question without posting


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