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Doctor did an excision of a keloid scar from ear. Problem here is I dont see a size in operative report nor path. Here is report. Should I ask surgeron size because coding a keloid should be in integumentary code 11400-11446. Here is report, what do you think?So no size means I have to code it to smallest code ?11440 ?
OSTOPERATIVE DIAGNOSIS: Hypertrophic scar, right ear lobe.
PROCEDURE PERFORMED: Excision of hypertrophic scar, right ear lobe.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in a supine position. The patient under adequate anesthesia prepped and draped around her right ear lobe in usual sterile fashion. Circumferential excisions were done along the anterior and posterior aspects of her hypertrophic scar with anterior aspect or lateral aspect being slightly more enlarged than the medial aspect or posterior aspect. Once totally excised, they were reapproximated with interrupted nonabsorbable suture. A bandage was applied as well as some ointment. The patient was awakened and transported to recovery room in satisfactory condition.
path report reads as follow :Sections show polypoid pieces of skin with hypertropic bundles. Hyalinzation and chronic inflamation are present. The findings are those of a keloid.
OSTOPERATIVE DIAGNOSIS: Hypertrophic scar, right ear lobe.
PROCEDURE PERFORMED: Excision of hypertrophic scar, right ear lobe.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in a supine position. The patient under adequate anesthesia prepped and draped around her right ear lobe in usual sterile fashion. Circumferential excisions were done along the anterior and posterior aspects of her hypertrophic scar with anterior aspect or lateral aspect being slightly more enlarged than the medial aspect or posterior aspect. Once totally excised, they were reapproximated with interrupted nonabsorbable suture. A bandage was applied as well as some ointment. The patient was awakened and transported to recovery room in satisfactory condition.
path report reads as follow :Sections show polypoid pieces of skin with hypertropic bundles. Hyalinzation and chronic inflamation are present. The findings are those of a keloid.