Hi! Would 54060 be appropriate here based on the method of excision (electrocautery and then cauterized the lesion) and location of the lesion? Or should I query the provider on the size of the lesion and bill 11420-11426? Pathology came back as seborrheic keratosis (benign). Thanks for your help!
POSTOPERATIVE DIAGNOSIS: Penile lesion.
PROCEDURE PERFORMED: Excision of penile lesion.
ANESTHESIA: General.
PERTINENT FINDINGS: Large mole/lesion noted on the left lateral proximal portion of the penile
shaft. This was successfully excised in its entirety with the skin reapproximated well.
INDICATIONS FOR PROCEDURE: 48-year-old male with a penile lesion
concerning for possible condyloma versus large mole and presents now for removal via excision.
PROCEDURE IN DETAIL: After proper informed consent was obtained, the patient was brought to
the operating room and laid supine on the operating room table. The patient was placed under monitored
anesthesia care. After proper time-out was completed, local anesthetic with a penile block was completed
using Marcaine. At this point, the lesion was identified on the left shaft proximal portion of the penile
shaft. Local anesthetic was then applied to raise up into the skin. A wide excision was then completed
and removal of the entire lesion was done successfully using sharp electrocautery using dissection. The
base was then cauterized and the skin was reapproximated using 4-0 Monocryl sutures in a horizontal
mattress fashion. The patient was then awoken from anesthesia and taken to the PACU in good stable
condition. The patient tolerated the procedure well with no complications.
DISPOSITION: The patient is to be discharged home to follow up in clinic.
POSTOPERATIVE DIAGNOSIS: Penile lesion.
PROCEDURE PERFORMED: Excision of penile lesion.
ANESTHESIA: General.
PERTINENT FINDINGS: Large mole/lesion noted on the left lateral proximal portion of the penile
shaft. This was successfully excised in its entirety with the skin reapproximated well.
INDICATIONS FOR PROCEDURE: 48-year-old male with a penile lesion
concerning for possible condyloma versus large mole and presents now for removal via excision.
PROCEDURE IN DETAIL: After proper informed consent was obtained, the patient was brought to
the operating room and laid supine on the operating room table. The patient was placed under monitored
anesthesia care. After proper time-out was completed, local anesthetic with a penile block was completed
using Marcaine. At this point, the lesion was identified on the left shaft proximal portion of the penile
shaft. Local anesthetic was then applied to raise up into the skin. A wide excision was then completed
and removal of the entire lesion was done successfully using sharp electrocautery using dissection. The
base was then cauterized and the skin was reapproximated using 4-0 Monocryl sutures in a horizontal
mattress fashion. The patient was then awoken from anesthesia and taken to the PACU in good stable
condition. The patient tolerated the procedure well with no complications.
DISPOSITION: The patient is to be discharged home to follow up in clinic.