Squamous cell carcinoma of the scalp procedure

jticbs

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Orange, Anaheim, Los Alamitos CA
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Hi everyone, I need help with the case below:


Preoperative Diagnosis: Squamous cell carcinoma of the scalp

Postoperative Diagnosis: Squamous cell carcinoma of the scalp

Operation: Wide local excision 2 cm squamous cell carcinoma of the scalp with closure

Procedure: The patient was taken to the Operating Room and administered intravenous sedation. The scalp was anesthetized with 10 cc of local anesthesia with epinephrine. The areas was prepped and draped in standard fashion. The patient has a 1 cm lesion on the back of the scalp. Margins were obtained resulting in a defect measuring 2 cm x 2 cm. The lesion was tagged and sent to Pathology for frozen section with diagnosis of squamous cell carcinoma with clear margins. Local undermining of the scalp was performed and lateral to medial advancement flaps were now performed with incision and release of the galea laterally followed by primary closure with #3-0 Vicryl. The skin was then closed with stainless steel staples. Merocal was placed on the wound after it was approximated as well with Dermabond. Sponge and needle counts were correct and there were no complications. The patient tolerated the procedure well and was taken to the Post Anesthesia Care Unit in stable condition.


Diagnosis Code(s): 173.42

Procedure Codes: 11626 (excision of malignant lesion of scalp over 4.0 cm diameter
13121 (repair, complex of scalp 2.6 - 7.5 cm

Above are my code. I just want to verify I code correctly. I have trouble understanding the procedure in term of calculating the lesion plus the margin and the closure ( simple, intermediate, complex). What is the key word from the report that lead me to choose the level of closure...... please help. I really appreciate it.
 

Susan

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Chandler, AZ
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I agree that this is an Adjacent Tissue Transfer or Rearrangement and based on your documentation of 2 x 2 that would be 4 squared, CPT 14020 would be the only CPT code to report.
 
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