Wiki Mulipule Excision- Malignant lesions

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midnight1995

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Need so help with this multiple excision - First time I have encounter this amount of excision's. The physician coder over 30 CPT codes.

> diagnosis:
1.) History of metastatic melanoma with unknown primary of the left lower extremity.
2.) Squamous cell carcinoma of the bilateral lower extremities with multiple lesions
3.) Right upper arm lesion at a prior burn scar consistent with developing squamous cell carcinoma

> Operation:
1.)Wide local excision of right lower extremity: 15 cm X 21 cm.
2.) Wide local excision of right lower extremity: 1 cm X 3 cm.
3.) Wide local excision of right lower extremity: 0.5 cm X 2 cm.
4.) Wide local excision of right lower extremity: 5 cm X 2 cm.
5.) Wide local excision of right lower extremity: 3 cm X 1.5 cm
6.) Wide local excision of right lower extremity: x14, 1 cm X 1 cm.
7.) Wide local excision of right lower extremity: x10, 5 mm X 5 mm.
8.)Wide local excision of right lower extremity: 12 cm X 4 cm
9.) Delayed primary closure with reconstruction using shin flaps of the left lower extremity wound, 2 cm X 8 cm.
10.) Delayed primary closure with reconstruction using skin flaps of the left lower extremity wound 2 cm X 6 cm.
Thanks for help
Carolyn Lewis CPC,PCA
 
body of the note

The lesions were all numbered preoperatively and pictures were taken with the plan for excision of 29 areas with lesions. We also excised the right upper extremity lesion. We 1st stated the dissection with the largest pretibial lesion 1st by using a 10 blade circumferentiallly and then using electrocautery further resection down to the fascia. I then marked this short superior, long lateral. i then turned my attention to the sequentially until lesion #2 through 29 and resected with the electrocautery. when there were large enough, we placed a suture superior to mark the specimen. afer complete resecont of all these lesions, the largest lesion was not able to be closed. the other lesions were closed with combination of staples and 2-0 nylon sutures. i then turned my attention to the right upper extremity lesion, which was just over 60$ of the circumference over right upper arm, where a prior burn from boiling hot water had caused a scar, which was now developing what appeared to be a new squamous cell carcinomas. i used fusiform excision for this are and 12 cm X 4 cm; 12 cm been on transversus direction. i then raised a skin flap superiorly and inferiorly and closed with staples. i hen turned my attention to 2 lower extremity lesions in the left lower extremity, one on the lateral pretibial space and 1 on the lateral thigh. there were 2 elongated areas that i change into fusiform patterns and raised skin flaps on both directions that were able to close with staples.

Thanks
 
Personally, I don't think you have sufficiently detailed documentation to be able to code this - I would query the physician for revised documentation. If these are 29 or 30 separate excisions, you need documentation for each of the procedures, including the size and location of each lesion and the margins, the pathology, the size of each defect and the manner of closure. Each excision and each closure should be a separately documented procedure. This is more a summary than an operative note and I think most payers would not accept this documentation to support charges for multiple separate lesion excision and closure CPT codes. Alternatively, you could bill this with a single unlisted code and let the payer make their own determination of the appropriate payment.
 
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