Wiki Question about Malignant Code

tholcomb

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Good morning all,

I have a question regarding which cpt code should be used for the operative report below
cpt code 11622 or 11623? :confused:

Thank you,
TH

The patient was brought to the operating room, placed on the
operating room table in a supine position who underwent general
anesthesia by the anesthesiology service without complications.
A time-out was held in accordance with institutional policy. No
antibiotics or DVT prophylaxis were utilized. The left temporal
scalp was prepped and draped in the usual sterile fashion. A
ruler and marking pen were used to mark a 5 mm margin of excision
encompassing a total resection margin of 2 x 1 cm. The site was
infiltrated with local anesthetic containing 1% Xylocaine with
epinephrine and 0.25% Marcaine mixed. The skin was excised in an
elliptical fashion with a 15 blade scalpel. Electrocautery was
used to excise the lesion, and it was oriented with a short silk
suture on the superior aspect and a long silk suture on the
lateral aspect. The wound was irrigated with saline solution and
hemostasis was achieved. The wound was closed primarily with 3-0
Vicryl subdermal stitches and the skin was reapproximated with a
4-0 Monocryl subcuticular suture. Dermabond was placed and a
sterile Band-Aid was put on the incision. The patient tolerated
the procedure well and was brought to the recovery room in stable
condition. The sponge and needle counts were correct at the end
of the operation. The attending physician was present for the
entire period.
 
5 mm margins, 1 cm across, 2 cm length. No indication of lesion size, so it's possible the surgeon is re-excising for margins and no visible lesion is left or s/he didn't dictate the whole story. If it's really just 1 cm, I would code for 11621 (using lesion size 0.0 and most narrow margins needed). The 2 cm length is to accommodate the closure.

Hope that helps. :)
 
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