# Excision- help coding please



## ksb0211 (Jan 14, 2011)

I'm hoping to get the input of some other coders. After speaking with someone else, we have 2 completely different ideas on what should be coded. Any other input would be greatly appreciated. This may be a bit lengthy, but I want to include the entire scrubbed op report for clarity. 

Diagnoses:
1. Melanoma, left upper extremity
2. Lesion, left antecubital fossa

Description of Procedure:
The patient was admitted and brought to the Nuclear Medicine Department where radioisotope injection was done in the region of the lesion of the left upper extremity which was at the distal forearm, dorsal aspect. Computerized axial tomography (CAT) scan was performed and a lymph node was noted in the axilla on the left side. The patient was then taken to the operating room. He was placed under general anesthesia. The left upper extremity and right thigh were prepped with DuraPrep and draped sterilely. The axillary portion of this procedure was performed first. Utilizing the Neoprobe this area in question was identified. The patient was noted to have mutliple fatty nodes in the left axilla. The nodes with increased activity were well identified. Two lymph nodes of significance were passed off as specimen. Frozen section was reported as negative for metastatic disease. Additional tissue was sent for permanent section. Once this was completed the decision was that the patient would not need an axillary dissection. The wound was inspected for hemostasis. The axillary incision which had been placed high in the axilla in the skin fold just posterior to the pectoralis major muscle was then closed in layers utilizing 2-0 Vicryl to the deep tissue and 4-0 Vicryl subcuticular stitch.

Attention was then turned to the left forearm. Approaching the antecubital crease on the left side, a raised skin lesion was appreciated. Some scar tissue was appreciated within this area. A fishmouth incision was made trying to totally encompass this lesion. Some undermining was required. The wound was then closed in layers utilizing 4-0 Vicryl to the deep tissue and 4-0 nylon vertical mattress sutures to the skin. Specimen was passed off.

With this completed attention was then turned to the area in question in the dorsal aspect of the left forearm. This site of the melanoma had been injected with radioisotope as well as methylene blue. The wide local incision was performed utilizing at least 1.5 centimeter margin from the area of scarring. The incision was carried down through the subcutaneous tissue to the subcutaneous fat. Specimen was passsed off. It was clear that there was not enough laxity of tissue and a skin graft would be required. The round dermatome was then utilizied on the right thigh, 12/1000ths of an inch thickness skin graft was taken measuring approximately 4 centimeters by 7 centimeters. It was then placed throguht the 1:3 meshing device. It was placed on the wound intact and placed circumferentially with interrupted 4-0 Vicryl suture. Xeroform was then placed with Bactroban antibiotic ointment as well as moistened gauze. Sterile dressing was applied, The patient tolerated the procedure. No intravenous antibiotics had been adminitered. A dry sterile dressing was applied tot he donor site on the right thigh. The patient was taken to the recovery room in stable condition.


I appreciate any input whatsoever.
~Kelly~


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