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Biopsy again

  1. #1
    Default Biopsy again
    Medical Coding Books
    can someone help me with the op report

    Preop Dx: a skin lesion of the left palm

    Operations: Shave biopsy of the skin lesion of the left palm.

    Procedure in detail: This is a 52 year old man who had about a 2 cm x 2 cm skin lesion of the palm of the left hand. It appeared to be some sort of keratic lesion. However, it had been growing and we wished to obtain a biopsy to make sure this lesion was benign. Plan is to obtain a biopsy and refer the patient to Dermat if indeed it is a benign lesion. Therefore, the wound was prepped and using 0.5% Marcain plain, this was injected in and around the lesion. Using a #15 blade, two small areas of the lesion were removed and sent to pathology. The wound was cleaned and a pressure dressing was applied and the patient will follow up with me in a week and we will setup his Dermatology refferal and know the pathology at that time.

  2. #2
    Icd-9: Depends On Path....most Likely Benign 216.6 Since It Mentioned That It's Most Likely A Keratosis(702.8)

    Otherwise, Malignant Is 173.6

    Cpt: 11308, Shave Biopsy Excision

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