Wiki Skin Mass Excision

ch81059

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Ethel, LA
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Hi,

I'm not sure how to determine what to use as the measurement of this mass. It says excision of mass 4.5 x 3.5 x 2.5. Would it be 4.5 or would I need to multiple by 3.5. I'm just not really sure. Any input is appreciated.

Thanks!

REPORT OF PROCEDURE
The patient was given preoperative IV antibiotics and subcu heparin, and
SCDs were placed to bilateral lower extremities. The patient was then
taken to the operating theater and placed supine on the operating table.
After adequate IV sedation by Anesthesia, the patient's right groin was
prepped and draped in standard sterile surgical fashion. Prior to all
skin incisions, local anesthesia of 0.5% Marcaine with epinephrine was
used.

A right groin incision was made over the palpable mass. Electrocautery
was used to dissect deep dermal layers. Care was taken to excise the
mass in toto which was size 4.5 x 3.5 x 2 cm. This mass was suspicious
for conglomerate of lymph nodes. This mass was sent to Pathology fresh
for lymphoma protocol. It also will be sent for permanent sectioning.
The incision was copiously irrigated with sterile water which was
suctioned from the site. Hemostasis was achieved and confirmed per
visual inspection. The incision was then closed in layers with 3-0
Vicryl in running fashion for deep dermal and 4-0 Monocryl in running
fashion for the skin. Steri-Strips and clean sterile pressure dressing
were applied.

All counts were correct at the end of the case. The patient tolerated
the procedure well and without complications and was returned to the
recovery room awake, alert, and in good condition.
 
skin mass excision

Since guidelines state square centimeters, I beleive you would have to multiply the measurements given to obtain the correct sq cm in order to code. My calculations come to 39.375 total sq cm. If anyone can verify my method, please do so. Is this correct?
 
skin mass excision

Sorry, I think I am referring to debridement, not actual excision. For excisions, the surgical guidelines are to code including the margins stated by surgeon. If the dictation does not specifically document the size including the margins, we are to use the lowest size in the anatomical site (diameter).
 
Lesion

It does not matter the highest it goes for excision of a lesion is 4.0 on any given part of the skin. But have you thought about 38760.
 
True, 38760 might be the best choice since it was actually lymph nodes that were removed. Thank you both for your help!
 
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