Wiki SCC excision forehead with bone removal for clear deep margin

[jfolz]

Coding for an outpatient hospital surgery dept... Does anyone have a suggestion on how to code a "frontal scalp SCC excision 5x4 with burring of the outer cortex of the skull"?

From the Op Note:"...complicated history with multiple attempted excision by Mohs surgery and additionally has had radiation therapy to the area. He unfortunately now has a reoccurrence of this aggressive tumor. Pt is found to have a large right frontal scalp SCC with multiple satellite skipped lesions. This was excised down to the underlying skull, 5x4cm, removing the periosteum. This was sent for intraoperative frozen section, which indicated clear margins, however, there was a very close deep margin superiorly where a little bit of the periosteum was left. Re-excision of the periosteum along the anterior deep margin was performed and sent for frozen section which indicated we had clear margins. Next utilizing a cutting burr, the outer cortex of the skull was then drilled down to the diploic layer. Pinpoint bleeding was identified. The wound was irrigated. We then applied acellular dermal allograft to the scalp. This was placed dermal side down into the defect and trimmed. It was then sutured..."

I am questing his intent with the bone burring. (I have read it so many times I am now questioning my comprehensive skills.) I *was* thinking it was to take a deeper margin and insure this was taken in total but I am now thinking it was only to maximize the change of the allograft's survival after placement.

I am trying to avoid craniotomy, which is in-patient only and seems much more extensive than the procedure that was performed. I considered coding it unlisted and comparing to 21137? There just are not many codes in the minor skull removal area...
If the intent was only to provide a receptive bed for the graft, this may be a non-issue.

 

[danachock]

Hi jfolz,
As a pathology coder, I do not question their intent with the bone burring. Yes, the pathologist stated "clear margins" but there was a very close deep margin where superiorly where a little bit of the periosteum was left. When a surgeon is faced with a malignant neoplasm - you need to have "clear" margins in the pathology world. I do not know the "margins" necessary for every scenario or type of malignancy - that is entirely in their realm, I am simply a pathology coder. However, since the intraoperative was performed I am somehow believing communication was happening between the pathologist and surgeon that we are not privileged too.
But reading your post it wasn't achieved yet when they had stated "very close". We don't have that discussion between surgeon and pathology, or any idea the type of malignancy the patient has, to even guess the margins necessary to be in the pathology world "clear". So please, forgive me if you or anyone else disagrees reading this scenario, but I don't believe that this has anything to do with the allograft. They wanted to achieve "proper" margins and eliminate the malignancy entirely without reoccurrence.
I will throw out an example - breast lumpectomy for cancer with a "positive margin" - and the surgeon returns to the OR again (not frozen section, entirely different DOS (day of service) to take more sampling (not usually a biopsy but another lumpectomy) for clear margins.
Thank you for listening and have a wonderful evening,
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT

 

[sthomso4@jh.edu]

I thought this helped:

It's from a study performed on patients to determine whether outer table drilling was helpful, so it explains why it was performed:


Results: Seventeen patients underwent outer table resection at an average age of 79.3 years. All had invasion of the pericranium with a mean surface area of 42.6 cm 2 . Eight patients had prior radiation treatment for SCC of the scalp and 12 patients had at least 1 prior surgery to attempt excision of their lesions. Two patients had local recurrence for a local control rate of 88.2% (15/17). One patient with metastasis prior to presentation, died 6 months after his initial surgery for disease-free survival rate of 94.1% (16/17) at a mean of 15.4months. Thirteen patients were able to achieve immediate reconstruction with local flaps with or without additional skin grafting (76.5%).

Discussion: The data in this study supports that in instances of locally invasive primary SCC of the scalp that extends to the pericranium, excision down to the calvarium with complete circumferential and deep peripheral margin assessment, followed by resection of the outer table, is an excellent option. The low rate of local recurrence and high disease-free survival in this study support that this method allows for optimal oncologic outcome while mitigating the significant morbidity associated with the alternative option of a full thickness craniectomy.