reconstruction of Mohs wound


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we had a new patient come in who had Mohs surgery on the top of his ear over 4 years ago by another surgeon not affiliated with our practice. he now wants to have this reconstructed as it left a notch on the top of his ear. Dr feels he can bill w/ the original skin CA ICD 9 code, but i don't know since it was so long ago and he documented in his notes that there was no evidence of recurrence. we don't have a copy of his records, path from other dr. does anybody have an idea?

A notch? A scar or deformity of the site is not coded with the cancer code at this point (with no evidence of disease).

Was something sent to pathology by your doctor?
you would code the acquired deformity with the history of cancer code. You cannot code the cancer as it is no longer present. The fact that they did a MOHS tells you this as that procedure is considered the definitive therapy for the cancer. Look up deformity, ear, acquired. Be certain you do not select a code in the congenital anomaly chapter.
re: the notch - that is just the how it appears in the dr's diagram. he did not take a picture. imagine Holyfield's ear after he was bitten. sorry, that's the only way i can describe it.
Dr. only did evaluation, so no there is no pathology by us.