I would like more feedback for this scenario
biopsy for the face came back as actinic keratosis:
coder 1 (14300 + 11441) after reading of path report.
coder 2 (67961 +14060 +11310) without reading of path report
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Unusually complicated excision and reconstruction of left lower lid.
INDICATIONS: This is an otherwise healthy 83-year-old male who has had a history of multiple skin cancers. He had developed an ulcerative lesion measuring over 0.5 cm with irregular margins on the left lower lid. He also had keratotic lesions on his right forehead and left cheek, measuring about 1.5 cm. He was taken to the Operating Room for wide excision of the basal cell carcinoma of the left lower lid and reconstruction with flaps and/or grafts, under frozen section control, with permanent biopsies of the forehead and left cheek.
PROCEDURE IN DETAIL: The patient's face was prepped and draped in the usual manner utilizing Betadine soap and solution. The lesion on the left lower lid was then drawn out in a diamond pattern. The area was infiltrated with 1% Xylocaine with epinephrine and a period of ten minutes was allowed for the hemostatic effects as evidenced by blanching. The lesion was then excised en bloc. A suture was placed at the 12 o'clock position. However, it became evidence that there was suspicious tissue in the underlying margin of the wound. The base of the wound was then trimmed in the suspicious area, and this was sent with the first specimen. Though labeled as one specimen, they were individually frozen and examined. This came back as the margins clear on the original specimen, but the base was positive in the secondary specimen of Specimen #1, loaded with basal cell carcinoma. At this point, we were into the muscle. A secondary 100% margin of the wound was then made. With unusually complicated, meticulous dissection, the entire base of the wound, contiguous with the 360° margins was painstakingly dissected free, trying to preserve as much of the underlying structures as possible. Meticulous hemostasis was achieved with electrocautery, and this was done with loop magnification. Eventually, the entire wound, with its new margins, was excised en bloc, and a suture placed at the 12 o'clock position. The specimen was sent to frozen section and came back with residual tumor, but margins positive, both deep and peripheral. At this point, we were left with one-third of the eyelid missing. A large Limberg transposition flap was then designed on the cheek to be rotated and brought up into the defect. The flap was marked and infiltrated. It was then mobilized with blunt and sharp dissection. It was evident that there would still be some ectropion. Then, soft tissue expansion was progressively performed until there was enough laxity to lay in the flap without pulling or distorting the eyelid. Meticulous hemostasis was achieved with electrocautery. The wound was irrigated with a clindamycin-gentamicin solution. The donor site was then undermined and advanced for primary closure. This as repaired with interrupted 6-0 Prolene sutures, mattress sutures, to take up the tension on the deep tissues. The flap was then thinned out toward the top and rotated into the defect. This was meticulously repaired with interrupted 6-0 Prolene sutures until the entire wound was closed primarily without any ectropion. Benzoin and Steri-Strips were applied, as the wound was stented.
Attention was then turned to the other lesions, which were tangentially excised down to a punctate bleeding base and sent to Pathology, labeled right forehead and left cheek.
Numerous other keratotic lesions in the face were then scraped down and treated with antibiotic solution.
The patient tolerated the procedure well and left the Operating Room in stable condition.
biopsy for the face came back as actinic keratosis:
coder 1 (14300 + 11441) after reading of path report.
coder 2 (67961 +14060 +11310) without reading of path report
PREOPERATIVE DIAGNOSIS:
- Basal cell carcinoma of the left lower lid.
- Lesions of uncertain behavior, right forehead and left cheek.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Unusually complicated excision and reconstruction of left lower lid.
INDICATIONS: This is an otherwise healthy 83-year-old male who has had a history of multiple skin cancers. He had developed an ulcerative lesion measuring over 0.5 cm with irregular margins on the left lower lid. He also had keratotic lesions on his right forehead and left cheek, measuring about 1.5 cm. He was taken to the Operating Room for wide excision of the basal cell carcinoma of the left lower lid and reconstruction with flaps and/or grafts, under frozen section control, with permanent biopsies of the forehead and left cheek.
PROCEDURE IN DETAIL: The patient's face was prepped and draped in the usual manner utilizing Betadine soap and solution. The lesion on the left lower lid was then drawn out in a diamond pattern. The area was infiltrated with 1% Xylocaine with epinephrine and a period of ten minutes was allowed for the hemostatic effects as evidenced by blanching. The lesion was then excised en bloc. A suture was placed at the 12 o'clock position. However, it became evidence that there was suspicious tissue in the underlying margin of the wound. The base of the wound was then trimmed in the suspicious area, and this was sent with the first specimen. Though labeled as one specimen, they were individually frozen and examined. This came back as the margins clear on the original specimen, but the base was positive in the secondary specimen of Specimen #1, loaded with basal cell carcinoma. At this point, we were into the muscle. A secondary 100% margin of the wound was then made. With unusually complicated, meticulous dissection, the entire base of the wound, contiguous with the 360° margins was painstakingly dissected free, trying to preserve as much of the underlying structures as possible. Meticulous hemostasis was achieved with electrocautery, and this was done with loop magnification. Eventually, the entire wound, with its new margins, was excised en bloc, and a suture placed at the 12 o'clock position. The specimen was sent to frozen section and came back with residual tumor, but margins positive, both deep and peripheral. At this point, we were left with one-third of the eyelid missing. A large Limberg transposition flap was then designed on the cheek to be rotated and brought up into the defect. The flap was marked and infiltrated. It was then mobilized with blunt and sharp dissection. It was evident that there would still be some ectropion. Then, soft tissue expansion was progressively performed until there was enough laxity to lay in the flap without pulling or distorting the eyelid. Meticulous hemostasis was achieved with electrocautery. The wound was irrigated with a clindamycin-gentamicin solution. The donor site was then undermined and advanced for primary closure. This as repaired with interrupted 6-0 Prolene sutures, mattress sutures, to take up the tension on the deep tissues. The flap was then thinned out toward the top and rotated into the defect. This was meticulously repaired with interrupted 6-0 Prolene sutures until the entire wound was closed primarily without any ectropion. Benzoin and Steri-Strips were applied, as the wound was stented.
Attention was then turned to the other lesions, which were tangentially excised down to a punctate bleeding base and sent to Pathology, labeled right forehead and left cheek.
Numerous other keratotic lesions in the face were then scraped down and treated with antibiotic solution.
The patient tolerated the procedure well and left the Operating Room in stable condition.