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10-06-2011, 10:05 AM
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Removal of a lesion not sure what cpt to use.
Questioning what cpt to use for this procedure due to my provider using the ellman unit to remove and sent out lesion. The path report says shave so if I go that way Im coming up with 172.6/11302 or if I go with just bx 172.6/11100. Just let me know what you think. Thanks
Primary Provider: CC: lesion removal Lt forearm. History of Present Illness: presents for lesion removal. Past Medical History: Reviewed history from 12/13/2010 and no changes required: Type II DM with neuropathy Dyslipidemia HTN CVD - s/p R carotid endarterectomy, 2010 CAD - diffuse disease - medical management advised Past Surgical History: Reviewed history from 12/13/2010 and no changes required: R 5th toe amputation L spine surgery R Carotid Endarterectomy, 2010 Social History: Reviewed history from 04/30/2010 and no changes required: Married, 5 kids Risk Factors: Tobacco use: quit Year quit: 1969 Pack-years: 4.5 Passive smoke exposure: no HIV high-risk behavior: no Caffeine use: Drinks coffee 1-2 times per day. Alcohol use: yes Type: Drinks wine 1 time per month having 1-2 per occasion. Never has more than five drinks per occasion. Exercise: yes Times per week: 3-4 /wk Type: walking Seatbelt use: 100 % Sun Exposure: occasionally Family History Risk Factors: Family History of MI in females < 65 years old: no Vital Signs: Patient Profile: Years Old Male Weight: 289.2 pounds Temp: 96.5 degrees F tympanic Pulse rate: 68 / minute Pulse rhythm: regular BP sitting: 130 / 74 (right arm) Cuff size: large Vitals Entered By: Physical Exam Skin: 1 cm squamous cell cancer appearing lesion on left forearm Impression & Recommendations: Problem # 1: SKIN LESION (ICD-709.9) Remove today. If SCC will need referral for re-excision and possibly Mohs. The lesion was cleansed with betadine, anesthetized with 2% Lidocaine with epi and removed with the Ellman unit utilizing a loop/shave technique without complications. Hemostasis assured, dressing applied and wound care instructions given. Orders: Excision of Lesion (EXCLES) PATH Patient: ID: Note: All result statuses are Final unless otherwise noted. Tests: (1) SKIN, OTHER THAN CYST/TAG/DEBRIDMENT (SKO1) ! SURG201109301621 "Result Below..." RESULT: Specimen Source: A. LEFT FOREARM (R) Ordering Physician: Patient Name: Gender: PATHOLOGIC DIAGNOSIS: Skin, forearm, left, shave biopsy: - Malignant melanoma, spindle cell and desmoplastic types, present at inked margin. - Ulceration: Not identified. - Breslow thickness: 2.2 mm. - Clark level: IV. - Margins: Invasive melanoma extends to deep and lateral inked margins, hence, Breslow thickness and Clark level are provisional. - Lymphvascular space invasion: Not identified. - Perineural invasion: Not identified. - Tumor regression: Present, involving 50% of the lesion. - Lymphocytic host response: Present, brisk. - Pre-existing lesion: Not identified. - Mitoses: Greater than 1 per mm2. - AJCC pathologic staging: T3a NX MX. COMMENT: Melan-A and S-100 immunohistochemical stains are performed in order to assess for a desmoplastic melanoma show positive S-100 staining in the spindle cell component (diffusely strongly positive with scattered staining of ovoid cells throughout the sclerotic dermis) and negative staining for Melan-A with alkaline phosphatase counterstain in many spindled melanocytes and all the epithelioid cells within the sclerotic dermis. Melan-A highlights atypical junctional melanocytes. S-100 also highlights nerves, dendritic cells and macrophages. CD68 immunohistochemical stain is performed in order to differentiate dermal macrophages from epithelioid melanocytes within the sclerotic dermis and is diffusely positive. An S-100 (red) and CD68 (brown) combined immunohistochemical stain shows scattered few S100 positive cells within the sclerotic component. This stain is inconclusive and hence there is no charge for this dual stain to the patient. The Breslow thickness reported measures to the deepest melanocyte of the spindle cell component. The Breslow thickness of the sclerotic component is 5.0 mm, but this may represent an area of regression. CLINICAL HISTORY: 709.9 (unspecified disorder of skin and subcutaneous tissue). Additional clinical history obtained is that the lesion has been present for one year and has been growing. Previous biopsy from this site has not been performed. GROSS DESCRIPTION: The specimen, labeled and designated, forearm, left," is received in formalin and consists of a 1.0 x 0.8 x 0.6 cm, tan, rubbery, and pitted shave of skin that is inked and trisected. All in (A1). pk  CH:ksw__________________________________________________ _____________________ 
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