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Excisions

jrs3181

Contributor
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OK...my eyes are crossing. Here is the OP Note and how I think it should be coded.

PREOPERATIVE DIAGNOSES: Right lower facial atypical skin neoplasm, right lower nasal squamous cell carcinoma, left lower nasal basal cell carcinoma, and upper nasal actinic keratosis.

POSTOPERATIVE DIAGNOSES: Right lower facial atypical skin neoplasm, right lower nasal squamous cell carcinoma, left lower nasal basal cell carcinoma, and upper nasal actinic keratosis.

PROCEDURES: Excision of right lower facial and upper neck basal cell carcinoma with local flap reconstruction, excision of right and left lower nasal skin carcinoma, and ablation cauterization of upper nasal actinic keratosis.


INDICATIONS: This is an 85-year-old male with a long history of multiple skin carcinomas and actinic changes and seborrheic keratoses. The patient had recent biopsies of two lower nasal lesions both consistent with carcinoma and the right lower facial lesion suspicious for malignancy. The patient also had some roughened area in the upper nasal area consistent with actinic keratosis. It was felt that the patient would benefit from the aforementioned procedure.

DESCRIPTION OF PROCEDURE: The patient was brought in the suite, placed in supine position, under general anesthesia. The right facial area and nasal area were sterilely prepped and draped using the needle-tip cautery. Ablation of the upper nasal actinic keratosis was done. Bacitracin was applied at the end. The right lower facial lesion, which was just in the infraauricular area the upper neck, lower face was excised in an elliptical fashion at least 6 mm with normal appearing tissue surrounding it. A total defect size was 3.3 cm. A stitch was marked in 12 o?clock position and frozen section revealed basal cell carcinoma completely excised. A 30-degree transposition flap was created to help prevent deformity and tension on this area. This was elevated in subcutaneous tissues. Hemostasis was obtained with cautery. The area was copiously irrigated with half strength Betadine solution. Subcutaneous tissues were closed with interrupted 4-0 chromic. Skin was closed with interrupted 5-0 nylon. Mastisol, Steri-Strips, Bacitracin, and Glasscock dressing were placed at the conclusion of the procedure. The two lower nasal lesions were excised with at least which appeared to be 4 mm margin around the left lesion approximately 6 mm around the right as the right at least on biopsy. Initially, it was squamous cell carcinoma on the left basal cell. In any event, these were both excised. The lower nasal defect on the right was 1 to 1.1 cm and on the left was 1.2 to 1.3 cm. The right showed just reactive changes. No residual carcinoma was noted. The left showed basal cell carcinoma. Margins were clear. The area was copiously irrigated with half strength Betadine solution. Subcutaneous tissue was closed with interrupted 4-0 chromic. Skin was closed with interrupted 5-0 nylon. Mastisol, Steri-Strips, and Bacitracin were applied. The patient tolerated the entire procedure well. Estimated blood loss was than 10 cc.

14040 C44.310
11644 59 LT C44.310
11642 59 RT C44.301
11641 59 LT C44.301
17000 L57.0
 
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