Can someone help me and tell me if this is correct
11104
17110-59
17000-59
17003-59
Procedure
Punch Biopsy Procedure Note
Lesion 1:
Site: upper mid back
Indication: diagnostic
Clinical Impression: atypical nevus
Size: 6 mm
Punch Biopsy Size: 7 mm
Suture Closure: 3-0 ethilon suture - 2 simple interrupted
Anesthesia: 1 cc of 2% lidocaine with epinephrine
Patient was seen and examined today in the procedure room. Detailed explanation of the risks and benefits of the procedure were given to the patient and informed consent was signed. The patient was positioned to give optimal view of the questionable lesion. Alcohol was used to create a clean field. Anesthesia was completed with lidocaine as described above. The skin was then prepped with Chloroprep to create a sterile field. The skin was then tested for adequate anesthesia, and the procedure was completed in the standard fashion using the punch biopsy instrument listed above. Hemostasis was achieved with pressure/sutures. Topical Vaseline ointment and a dressing were applied. The patient tolerated the procedure well. Post-procedure care instructions were given immediately after completing the procedure
Specimen sent to pathology: yes
EBL: minimal
Complications: none
Cryotherapy procedure note
Clinical impression: 2 AKs on forehead, sebaceous hyperplasia on R nare
Indication: therapeutic
Verbal consent obtained detailing R/B/A of procedure: yes
Procedure:
Skin was not prepped with alcohol. Lesion(s) removed or destroyed using Cryogun. Total number of freeze/thaw cycles 1.
Total number of lesions: 3
Pathology report
Material submitted:
DERM, BACK - Skin, Upper Back, Biopsy:
Diagnosis: EARLY SEBORRHEIC KERATOSIS, INVOLVING THE PERIPHERAL BIOPSY MARGINS.
Gross description:
Received in formalin labeled with patient's name and date of birth, upper back is a 0.6 cm in diameter by 0.4 cm in length tan, cylindrical fragment with a variegated brown surface. The specimen is inked blue, bisected, and submitted in toto in 1 cassette. Grossing tech: GFI
Pathologist provided ICD-10:
L82.1
11104
17110-59
17000-59
17003-59
Procedure
Punch Biopsy Procedure Note
Lesion 1:
Site: upper mid back
Indication: diagnostic
Clinical Impression: atypical nevus
Size: 6 mm
Punch Biopsy Size: 7 mm
Suture Closure: 3-0 ethilon suture - 2 simple interrupted
Anesthesia: 1 cc of 2% lidocaine with epinephrine
Patient was seen and examined today in the procedure room. Detailed explanation of the risks and benefits of the procedure were given to the patient and informed consent was signed. The patient was positioned to give optimal view of the questionable lesion. Alcohol was used to create a clean field. Anesthesia was completed with lidocaine as described above. The skin was then prepped with Chloroprep to create a sterile field. The skin was then tested for adequate anesthesia, and the procedure was completed in the standard fashion using the punch biopsy instrument listed above. Hemostasis was achieved with pressure/sutures. Topical Vaseline ointment and a dressing were applied. The patient tolerated the procedure well. Post-procedure care instructions were given immediately after completing the procedure
Specimen sent to pathology: yes
EBL: minimal
Complications: none
Cryotherapy procedure note
Clinical impression: 2 AKs on forehead, sebaceous hyperplasia on R nare
Indication: therapeutic
Verbal consent obtained detailing R/B/A of procedure: yes
Procedure:
Skin was not prepped with alcohol. Lesion(s) removed or destroyed using Cryogun. Total number of freeze/thaw cycles 1.
Total number of lesions: 3
Pathology report
Material submitted:
DERM, BACK - Skin, Upper Back, Biopsy:
Diagnosis: EARLY SEBORRHEIC KERATOSIS, INVOLVING THE PERIPHERAL BIOPSY MARGINS.
Gross description:
Received in formalin labeled with patient's name and date of birth, upper back is a 0.6 cm in diameter by 0.4 cm in length tan, cylindrical fragment with a variegated brown surface. The specimen is inked blue, bisected, and submitted in toto in 1 cassette. Grossing tech: GFI
Pathologist provided ICD-10:
L82.1
