A plastics surgeon did an excision of left lower back and left upper back, separate excisions with closure.
Op note reads: I approached the lower back lesion. I excised it in a skin eclipse, taking it deeply into the subcutaneous fat. I undermined superior and inferior flaps, and was able to close without tension in a complex fashion. The subcutaneous tissue was closed using Vicryl and the skin was closed using 4-0 nylon.
I then proceeded to excise the large upper back lesion, which looked like a basal cell. It was excised in a skin ellipse, taking it deeply again to the subcutaneous fat. I undermined superior and inferior flaps and closed the defect with subcutaneous 4-0 Vicryl and the skin was closed using 4-0 nylon.
The lesion on the left lower back is over 3cm and the right upper back was 3cm . Pathology came back basal cell carcinoma on both specimens.
Physician office is stating that they coded 21936. I coded 13101 with 11603X2. Opinions please.
Thank you
Paula
Op note reads: I approached the lower back lesion. I excised it in a skin eclipse, taking it deeply into the subcutaneous fat. I undermined superior and inferior flaps, and was able to close without tension in a complex fashion. The subcutaneous tissue was closed using Vicryl and the skin was closed using 4-0 nylon.
I then proceeded to excise the large upper back lesion, which looked like a basal cell. It was excised in a skin ellipse, taking it deeply again to the subcutaneous fat. I undermined superior and inferior flaps and closed the defect with subcutaneous 4-0 Vicryl and the skin was closed using 4-0 nylon.
The lesion on the left lower back is over 3cm and the right upper back was 3cm . Pathology came back basal cell carcinoma on both specimens.
Physician office is stating that they coded 21936. I coded 13101 with 11603X2. Opinions please.
Thank you
Paula
