Hello, I have a question on this operative report codes billed are 99203-57, 11623-EXCIS MAL SCLP,NK,HND,FT,GENIT 2.1-3
Do you think that this report warrants an E/M with modifier 57? Looks to me like he was referred for the excision
Your help is greatly appreciated!!
Right hand dominant male who is referred for evaluation of left dorsal hand SCC. Pt had a shave biopsy which demonstrated invasive SCC present at the margin and he was referred to hand MOPS for surgical excision
Denies numbness/tingling.
Denies fevers/chills
Work history: retired
PAST MEDICAL/SURGICAL, SOCIAL, FAMILY HISTORIES, MEDICATIONS, ALLERGIES: Updated, reviewed and reconciled in Epic.
REVIEW OF SYSTEMS: Apart from the above history, the patient denies any gait abnormalities, fevers, joint pains, or rashes.
PHYSICAL EXAMINATION:
BP 128/78
Patient is awake, appropriate, alert and oriented times three, well-developed, well-nourished, and in no acute distress. Affect is appropriate. Their gait is stable and symmetric.
Examination of the bilateral hands reveals
Intact skin with capillary refill <2 seconds. There are 2+ palpable radial and ulnar artery pulses. Sensation in the median, radial and ulnar nerve distributions are grossly intact. The nailbeds are pink and the digits are well aligned with no instability where the patient has no complaints. There is full composite motion in all unaffected digits. There is 5/5 digit and wrist flexion and extension in the uninvolved areas.
On the dorsum of his left hand he has a 1cm circular shave biopsy site that is healing. Small amount of sero purulence over incision. No surrounding erythema.
IMAGING:
None indicated
Impression: Patient presents today with left dorsal hand SCC s/p shave biopsy w/ positive margins.
IMAGING:
None indicated
Impression presents today with left dorsal hand SCC s/p shave biopsy w/ positive margins.
Plan:
Plan for MOPS today.
PREOPERATIVE DIAGNOSIS: Left dorsal hand squamous cell carcinoma
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Excision of left dorsal hand squamous cell carcinoma
SURGEON:
MODE OF ANESTHESIA: Local only.
ESTIMATED BLOOD LOSS: Minimal.
IMPLANTS: None.
SPECIMENS: To pathology.
DRAINS: None.
CULTURES: None.
COMPLICATIONS: None.
DISPOSITION: Stable.
OPERATIVE REPORT: The patient was brought to minor operating suite and placed on the operating table in supine position. The upper extremity was prepped and draped in usual sterile fashion. After time out procedure, review of the the consent form, and laterality confirmation was performed, local anesthesia was administered around the lesion. 1% lidocaine with epinephrine was administered for a total of 5 cc using a 27-gauge needle.
A #15 scalpel blade was then used to create a 5cm-cm elliptical incision with 0.7mm of margin from the previous shave biopsy site. The soft tissue lesion was dissected out. The lesion was approximately 3.0cm in size. Care was taken to not injure any neurovascular or any other vital structures. The soft tissue lesion was sent to pathology.
After meticulous hemostasis was achieved, the skin edges were approximated using 5-0 nylon sutures in a simple fashion. The incision was dressed with Xeroform, sterile gauze and a loosely fashioned Coban wrap. There were no complications.
The patient tolerated the procedure well and was discharged home without complication.
Post-operative Plan:
1. Remove dressing on POD#3, may get incision wet. Keep covered with band-aid
2. Suture removal POD#10-14 and review of pathology report
Do you think that this report warrants an E/M with modifier 57? Looks to me like he was referred for the excision
Your help is greatly appreciated!!
Right hand dominant male who is referred for evaluation of left dorsal hand SCC. Pt had a shave biopsy which demonstrated invasive SCC present at the margin and he was referred to hand MOPS for surgical excision
Denies numbness/tingling.
Denies fevers/chills
Work history: retired
PAST MEDICAL/SURGICAL, SOCIAL, FAMILY HISTORIES, MEDICATIONS, ALLERGIES: Updated, reviewed and reconciled in Epic.
REVIEW OF SYSTEMS: Apart from the above history, the patient denies any gait abnormalities, fevers, joint pains, or rashes.
PHYSICAL EXAMINATION:
BP 128/78
Patient is awake, appropriate, alert and oriented times three, well-developed, well-nourished, and in no acute distress. Affect is appropriate. Their gait is stable and symmetric.
Examination of the bilateral hands reveals
Intact skin with capillary refill <2 seconds. There are 2+ palpable radial and ulnar artery pulses. Sensation in the median, radial and ulnar nerve distributions are grossly intact. The nailbeds are pink and the digits are well aligned with no instability where the patient has no complaints. There is full composite motion in all unaffected digits. There is 5/5 digit and wrist flexion and extension in the uninvolved areas.
On the dorsum of his left hand he has a 1cm circular shave biopsy site that is healing. Small amount of sero purulence over incision. No surrounding erythema.
IMAGING:
None indicated
Impression: Patient presents today with left dorsal hand SCC s/p shave biopsy w/ positive margins.
IMAGING:
None indicated
Impression presents today with left dorsal hand SCC s/p shave biopsy w/ positive margins.
Plan:
Plan for MOPS today.
PREOPERATIVE DIAGNOSIS: Left dorsal hand squamous cell carcinoma
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Excision of left dorsal hand squamous cell carcinoma
SURGEON:
MODE OF ANESTHESIA: Local only.
ESTIMATED BLOOD LOSS: Minimal.
IMPLANTS: None.
SPECIMENS: To pathology.
DRAINS: None.
CULTURES: None.
COMPLICATIONS: None.
DISPOSITION: Stable.
OPERATIVE REPORT: The patient was brought to minor operating suite and placed on the operating table in supine position. The upper extremity was prepped and draped in usual sterile fashion. After time out procedure, review of the the consent form, and laterality confirmation was performed, local anesthesia was administered around the lesion. 1% lidocaine with epinephrine was administered for a total of 5 cc using a 27-gauge needle.
A #15 scalpel blade was then used to create a 5cm-cm elliptical incision with 0.7mm of margin from the previous shave biopsy site. The soft tissue lesion was dissected out. The lesion was approximately 3.0cm in size. Care was taken to not injure any neurovascular or any other vital structures. The soft tissue lesion was sent to pathology.
After meticulous hemostasis was achieved, the skin edges were approximated using 5-0 nylon sutures in a simple fashion. The incision was dressed with Xeroform, sterile gauze and a loosely fashioned Coban wrap. There were no complications.
The patient tolerated the procedure well and was discharged home without complication.
Post-operative Plan:
1. Remove dressing on POD#3, may get incision wet. Keep covered with band-aid
2. Suture removal POD#10-14 and review of pathology report