codedog
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PREOPERATIVE DIAGNOSIS: Infiltrating basal cell carcinoma of the left cheek.
POSTOPERATIVE DIAGNOSIS: Infiltrating basal cell carcinoma of the left cheek.
OPERATION: Excision of infiltrating basal cell carcinoma of the left cheek with two excisions, total excision size 3.5 cm.
ASSISTANT: None.
PROCEDURE IN DETAIL:
This elderly patient presented to the office with a lesion of the left cheek which had been previously biopsied and was said to be an infiltrating or sclerosing basal cell carcinoma. She also had a small lesion of her lower lid on the left.
She was taken to the operating room and placed under adequate basal sedation. A generous 4 mm margin was marked around the lesion which was on the left medial cheek. The incision was carried down through the skin and subcutaneous tissue and through approximately the mid level of the fat. It was tagged at the 12 o'clock superior margin and submitted to the lab for frozen sections. In the meanwhile, the 2 mm lesion of the lower lid was biopsied off. No closure was performed.The pathologist indicated that the peripheral margins were clear but closed and that the deep margins were questionably involved. Since the deep margin was comprised of soft cheek fat, we discussed the issue and decided to do a permanent section. So, four additional margins around the periphery were taken and submitted to the lab and a new deep margin was submitted to the lab for permanent section. All these margins had true margins stained with methylene blue. A sterile dressing was then applied because she did not wish to proceed with a flap unless the margins were clear. The patient was then sent back to the recovery room in good condition with the anticipation that she will be brought back to the operating room on Tuesday once the margins have been determined.
MY question is can I also code what was in paragraph 2 that states the 2mm lesion of lower as lid as 11440 came cack a eyekid lesion -seborrheic keratosis ?
POSTOPERATIVE DIAGNOSIS: Infiltrating basal cell carcinoma of the left cheek.
OPERATION: Excision of infiltrating basal cell carcinoma of the left cheek with two excisions, total excision size 3.5 cm.
ASSISTANT: None.
PROCEDURE IN DETAIL:
This elderly patient presented to the office with a lesion of the left cheek which had been previously biopsied and was said to be an infiltrating or sclerosing basal cell carcinoma. She also had a small lesion of her lower lid on the left.
She was taken to the operating room and placed under adequate basal sedation. A generous 4 mm margin was marked around the lesion which was on the left medial cheek. The incision was carried down through the skin and subcutaneous tissue and through approximately the mid level of the fat. It was tagged at the 12 o'clock superior margin and submitted to the lab for frozen sections. In the meanwhile, the 2 mm lesion of the lower lid was biopsied off. No closure was performed.The pathologist indicated that the peripheral margins were clear but closed and that the deep margins were questionably involved. Since the deep margin was comprised of soft cheek fat, we discussed the issue and decided to do a permanent section. So, four additional margins around the periphery were taken and submitted to the lab and a new deep margin was submitted to the lab for permanent section. All these margins had true margins stained with methylene blue. A sterile dressing was then applied because she did not wish to proceed with a flap unless the margins were clear. The patient was then sent back to the recovery room in good condition with the anticipation that she will be brought back to the operating room on Tuesday once the margins have been determined.
MY question is can I also code what was in paragraph 2 that states the 2mm lesion of lower as lid as 11440 came cack a eyekid lesion -seborrheic keratosis ?
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