pJohnson15
Networker
I am needing help with this procedure for scar excision.
Reason for appointment:
The patient is here for re-excision of 2 skin cancer lesions. The small lesion on the left side of her nose was previously removed and the pathology showed it to be a BCC with the peripheral and deep margins involved. We also removed a suspicious lesion from her left shin and this was reported to be "atypical melanocytic proliferation compatible with evolving malignant melanoma in situ, margins appear narrowly clear by less that 0.1 cm in examined sections."
Procedures:
Informed consent obtained. Prep usual sterile fashion. Anesthesia 1 mL of lidocaine on the nose, and 5 mL of lidocaine with epinephrine on the shin. A full thickness skin elliptical incision was made with a #15 blade scalpel on the left side of the nose measuring 1.5 mm in width and 3 mm in length. This wound was closed with 5-0 clear prolene in simple interrupted fashion and dressed with triple antibiotic ointment. A full thickness skin elliptical incision was made with a #15 blade scalpel on the left shin containing the scar from previous excision and a margin or normal appearing skin measuring 1.0 cm in width and 2.3 cm in length. This wound was closed with 3-0 Nylon in vertical mattress fashion and dressed with triple antibiotic ointment and a Bandaid.
Pathology report:
Part A: shin - L SHIN
Part B: nose - LEFT NOSE
Part A: Dermal scar and biopsy site changes. No evidence of malignancy. - L90.5
Part B: Basal Cell Carcinoma, Nodular type. - C44.311
My question is regarding the scar. The only codes I can find is for complex repair (of scar revision), but I don't think the note matches that description. Does anybody know what would be more appropriate for this?
Thank you!
Reason for appointment:
The patient is here for re-excision of 2 skin cancer lesions. The small lesion on the left side of her nose was previously removed and the pathology showed it to be a BCC with the peripheral and deep margins involved. We also removed a suspicious lesion from her left shin and this was reported to be "atypical melanocytic proliferation compatible with evolving malignant melanoma in situ, margins appear narrowly clear by less that 0.1 cm in examined sections."
Procedures:
Informed consent obtained. Prep usual sterile fashion. Anesthesia 1 mL of lidocaine on the nose, and 5 mL of lidocaine with epinephrine on the shin. A full thickness skin elliptical incision was made with a #15 blade scalpel on the left side of the nose measuring 1.5 mm in width and 3 mm in length. This wound was closed with 5-0 clear prolene in simple interrupted fashion and dressed with triple antibiotic ointment. A full thickness skin elliptical incision was made with a #15 blade scalpel on the left shin containing the scar from previous excision and a margin or normal appearing skin measuring 1.0 cm in width and 2.3 cm in length. This wound was closed with 3-0 Nylon in vertical mattress fashion and dressed with triple antibiotic ointment and a Bandaid.
Pathology report:
Part A: shin - L SHIN
Part B: nose - LEFT NOSE
Part A: Dermal scar and biopsy site changes. No evidence of malignancy. - L90.5
Part B: Basal Cell Carcinoma, Nodular type. - C44.311
My question is regarding the scar. The only codes I can find is for complex repair (of scar revision), but I don't think the note matches that description. Does anybody know what would be more appropriate for this?
Thank you!