Preoperative Diagnosis: Subepidermal modular lesion of the forearm [reason for encounter] Procedure . Question
Answered step-by-step
Asked by ChancellorBravery103051
Preoperative Diagnosis: Subepidermal modular lesion of the forearm [reason for encounter] Procedure Performed: Excision of 2.0-cm lesion of the forearm Description of Procedure: Under local anesthesia, the 2.0-cm lesion was removed with 0.5-cm margins. The lesion was submitted to pathology. Bleeding was controlled with electrocautery, and the wound was closed with five vertical mattress sutures of 5-0 nylon. Polysporin and dressing were applied to the wound. Pathological Diagnosis: Well-organized basal cell carcinoma 1. Scan the documentation and record the main procedure to be located in the Alphabetic Index 2. Search the index for the main terms/subterms and record the code selections. What documentation is needed before a code selection is determined? 3. Review the code descriptions to determine what additional documentation is needed before you can accurately select a code. Coding guidance (listed before code 11400 of the CPT Professional Edition, or published in CPT Assistant) states that the code selection is determined by measuring the great clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the narrowest margins required equals the excised diameter). 4. Read the operative report and pathological diagnosis again to identify the additional documentation needed to clarify the selection. Was the lesion benign or malignant? 5. What CPT code should be reported? CPT
SCIENCE
HEALTH SCIENCE
NURSING
MC165 165
Preoperative Diagnosis: Subepidermal modular lesion of the forearm [reason for encounter] Procedure
