Wiki Which Dx to use?

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jh1991

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We did one shave biopsy and the path report came back as Inflamed AK with extremely focal areas of squamous cell carcinoma in situ. Margins negative for full thickness atypia/squamous cell carcinoma in situ. Actinic changes extend to involve peripheral and deep margins. Patient returned 13 days later for LN treatment to AK margins. Since the follow-up treatment is supposed to be the same as the initial charge, should I use L57.0 on both visits or the SCC code that was removed?
 
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jh1991 said:
We did one shave biopsy and the path report came back as Inflamed AK with extremely focal areas of squamous cell carcinoma in situ. Margins negative for full thickness atypia/squamous cell carcinoma in situ. Actinic changes extend to involve peripheral and deep margins. Patient returned 13 days later for LN treatment to AK margins. Since the follow-up treatment is supposed to be the same as the initial charge, should I use L57.0 on both visits or the SCC code that was removed?
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I would use the D04 codes. AK's have the likely possibility of becoming SCC if it does becomes skin cancer and the lesion you described SOUNDS LIKE it's an AK with signs of SCC. It's still a lesion with signs of cancer. Since it's in the "in situ" stage, I would think to use D04 codes. I wouldn't call it an AK anymore if there's already cancer forming in it. I would also code under the malignant destruction codes "172**" because the path supports the existence of malignancy.
 
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