reconstruction of Mohs wound

lillydog845

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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?

thanks
 

DeeCPC

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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?
 

mitchellde

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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.
 

lillydog845

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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.
 
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