ICD-10 Coding Snapshot
PREOP DIAGNOSIS: Basal Cell CA.
POSTOP DIAGNOSIS: Basal Cell CA. Prior BCC right lobe excised two years ago.
LOCATION: Medial right inferior helix.
PREOP SIZE: 1.4 x 1 cm
POSTOP SIZE: 2.7 x 2 cm
INDICATION: Poorly defined borders.
PLANNED RECONSTRUCTION: Wedge resection advancement flap.
DESCRIPTION OF PROCEDURE: Prior to each surgical stage, the surgical site was tested for anesthesia and re-anesthetized as needed, after which it was prepped and draped in a sterile fashion.
The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.
No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
ICD-10-CM Code(s): C44.212 Basal cell carcinoma of skin of right ear and external auricular canal
Z85.828 Personal history of other malignant neoplasm of skin
Rationale: Be careful when accessing the Neoplasm Table. This is a basal cell carcinoma; therefore, the first place to go is Skin, then the site. The helix is the outer rim of the ear, extending from the superior insertion near the scalp to the end of the cartilage at the earlobe. When Skin, helix, is referenced there are codes listed. But, a note also states, see also Neoplasm, skin, ear. Under Skin, ear, there are more specific breakdowns of basal cell carcinoma, squamous cell carcinoma, and specified type. This indicates the importance of following the notes in the book. If the see also note had not been followed, it would have lead the coder to the wrong code. This patient also has a history of previous basal cell carcinoma on the same ear; this information should be coded as it is pertinent to this encounter.