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Oral carcinoma excision

  1. #1
    Unhappy Oral carcinoma excision
    Medical Coding Books
    We have a case that the oral cancer was excised in one big excision which included the tonsil, soft palate, floor of mouth and tongue. We need help finding appropriate code. Here is a copy of the op report:

    The gastroscope was reintroduced into the stomach and the positioning of the PEG was inspected and noted to be adequate. Then, the intraoral tumor was resected. It occupied the right floor of mouth, extending to the right soft palate along the anterior tonsillar pillar. It extended into the posterior lateral corner of the tongue. It was not attached to the mandible. Bovie cuts were made across the soft palate to mark the superior margin. Then, a frozen section was taken at the superior margin and submitted for pathology. Then, the tonsil was dissected from the tonsillar fossa to give a wide medial margin. The tumor was on the anterior tonsillar pillar. It did not clinically extend into the tonsil but the tonsil was removed as mentioned to give a wide medial margin. Then, the tumor cut was extended across the posterior lateral tongue through the floor of mouth at about the area of the first molar. The incision was then carried along the gingiva onto the soft palate. An anterior and medial margin was taken and submitted for frozen section. The dissection was carried deep to include the inferior alveolar mucosa, the posterior floor of mouth, the posterior lateral tongue, tonsil, and portion of the soft palate. After this was removed, the mouth was packed with gauze pending the frozen sections. The neck was then prepped and draped and a curvilinear incision was made in the mid neck. Superior and inferior flaps were elevated in a subplatysmal plane. The inferior border of the submandibular gland was identified and the fascia was elevated from the submandibular gland to protect the marginal mandibular nerve. The posterior facial vein was transected and ligated. The branches of the facial artery were transected and ligated. The gland was then removed after identification of the lingual nerve and transection of the post ganglionic vessels and nerve. After removal of the submandibular gland, the fascia overlying the sternocleidomastoid muscle was incised and the fascial component rolled off the anterior border of the sternocleidomastoid muscle from the omohyoid muscle inferiorly to the mastoid tip superiorly. The spinal accessory nerve was identified and preserved. The spinal accessory nerve was traced superiorly and then the contents of level 2B were dissected from the paraspinous muscles and from the jugular vein and tucked under the spinal accessory nerve. Then dissection was continued inferiorly along the sternocleidomastoid muscle and the contents of the neck were dissected from lateral to medial until the jugular vein was encountered. The branches of the jugular vein were ligated and the soft tissue lateral to the jugular vein was removed with preservation of the phrenic nerve. The contents of the mid neck from the omohyoid to the hyoid were then removed with preservation superiorly of the hypoglossal nerve. The wound was copiously irrigated. Hemovac drains were placed and secured in place. The wound was closed in layers. Then the mouth was re-entered. The residual bleeding was controlled with bipolar cautery. The frozen section margins were negative. The lateral tongue was reapproximated to the gingiva and the soft palate was reconstructed. This left a defect in the tonsillar fossa which was left to granulate. The procedure was then complete.

    Any help would be appreicated.

    Thanks. Lisa

  2. #2
    Does anyone have any ideas on this??? We would appreciate any help on this. Thanks.


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