Can someone tell me if this is correct
11311
11310-59
Neoplasm of skin of forehead (D49.2)
Shave excision with electrodesiccation performed lesion left upper forehead likely
seborrheic keratosis. Will await pathology results. Shave excision lesion left middle
forehead suspicious for possible basal cell carcinoma. Will await pathology results.
Given deep invasion of lesion if malignant will need elliptical excision follow-up. Patient
informed. Telephone follow-up next week.
Procedure
Informed consent obtained. Sterile prep performed lesion left upper forehead and lesion left central forehead. Injection 0.5 cc 2% lidocaine with epinephrine to each lesion.
Shave excision performed lesion left upper forehead. Specimen sent to pathology. Electrodesiccation applied with good hemostasis. Procedure tolerated well without complication.
Shave excision performed lesion left central forehead. Specimen sent to pathology. Curettage performed followed by electrodesiccation. Procedure tolerated well. No complications.
Chief Complaint
Here for skin biopsies on forehead
History of Present Illness
Multiple skin lesions on the forehead evaluated at annual wellness visit. Here for biopsy of 2 atypical lesions 1 in the left upper forehead 1 in the left central forehead
Physical Exam
Skin
Skin and subcutaneous tissue: Abnormal. Left central forehead with 5 x 5 mm flesh-colored dome-shaped papule. Well-circumscribed margins.
Examination of the skin for lesions: Abnormal. Left upper forehead with 1 x 1 cm gray-brown hyperkeratotic papule. Has irregular margins. Asymmetric shape. Lesion right at the hairline.
Pathology
Material submitted: Part A: DERM, FOREHEAD - Skin, Left Upper Forehead, Biopsy: Part B: DERM, FOREHEAD - Skin, Left Central Forehead, Biopsy:
Diagnosis: Part A: SEBORRHEIC KERATOSIS, INVOLVING THE DEEP AND PERIPHERAL BIOPSY MARGINS. Part B: EARLY SEBORRHEIC KERATOSIS, INVOLVING THE PERIPHERAL BIOPSY MARGINS.
Gross description: Part A: Received in formalin labeled with patient's name and date of birth, L upper forehead is a 0.6 x 0.5 cm tan/brown fragment with a roughened surface. The specimen is inked purple, bisected, and submitted in toto in 1 cassette. Grossing tech: JLW. Part B: Received in formalin labeled with patient's name and date of birth, L central forehead is a 0.3 x 0.4 cm tan fragment with a roughened surface. The specimen is inked orange, bisected, and submitted in toto in 1 cassette. Grossing tech: JLW.
Pathologist provided ICD-10:
L82.1
11311
11310-59
Neoplasm of skin of forehead (D49.2)
Shave excision with electrodesiccation performed lesion left upper forehead likely
seborrheic keratosis. Will await pathology results. Shave excision lesion left middle
forehead suspicious for possible basal cell carcinoma. Will await pathology results.
Given deep invasion of lesion if malignant will need elliptical excision follow-up. Patient
informed. Telephone follow-up next week.
Procedure
Informed consent obtained. Sterile prep performed lesion left upper forehead and lesion left central forehead. Injection 0.5 cc 2% lidocaine with epinephrine to each lesion.
Shave excision performed lesion left upper forehead. Specimen sent to pathology. Electrodesiccation applied with good hemostasis. Procedure tolerated well without complication.
Shave excision performed lesion left central forehead. Specimen sent to pathology. Curettage performed followed by electrodesiccation. Procedure tolerated well. No complications.
Chief Complaint
Here for skin biopsies on forehead
History of Present Illness
Multiple skin lesions on the forehead evaluated at annual wellness visit. Here for biopsy of 2 atypical lesions 1 in the left upper forehead 1 in the left central forehead
Physical Exam
Skin
Skin and subcutaneous tissue: Abnormal. Left central forehead with 5 x 5 mm flesh-colored dome-shaped papule. Well-circumscribed margins.
Examination of the skin for lesions: Abnormal. Left upper forehead with 1 x 1 cm gray-brown hyperkeratotic papule. Has irregular margins. Asymmetric shape. Lesion right at the hairline.
Pathology
Material submitted: Part A: DERM, FOREHEAD - Skin, Left Upper Forehead, Biopsy: Part B: DERM, FOREHEAD - Skin, Left Central Forehead, Biopsy:
Diagnosis: Part A: SEBORRHEIC KERATOSIS, INVOLVING THE DEEP AND PERIPHERAL BIOPSY MARGINS. Part B: EARLY SEBORRHEIC KERATOSIS, INVOLVING THE PERIPHERAL BIOPSY MARGINS.
Gross description: Part A: Received in formalin labeled with patient's name and date of birth, L upper forehead is a 0.6 x 0.5 cm tan/brown fragment with a roughened surface. The specimen is inked purple, bisected, and submitted in toto in 1 cassette. Grossing tech: JLW. Part B: Received in formalin labeled with patient's name and date of birth, L central forehead is a 0.3 x 0.4 cm tan fragment with a roughened surface. The specimen is inked orange, bisected, and submitted in toto in 1 cassette. Grossing tech: JLW.
Pathologist provided ICD-10:
L82.1
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