dr. wants to bill 116xx and 12042 which is what I'm also leaning towards, but then he confuses me especially since he also mention under procedure heading (advancement of flap closure)?
DX: basal cell carcinoma of left postauricular mastoid area
Operation: Wide excision and an advancement of flap closure and frozen
Area measured approximately 3.5cm x 1.5cm and infiltrate of anesthesia was obtained using Xylocaine .5% with 1:200,000 epinephrine after prepping with alcohol.
The patient was then transferred to the operating room and placed on the operating room table in a semi-reclining position and the area prepped and draped in the usual sterile manner using Betadine.
Excision of the aforementioned area was carried out with the #15 blade and cautery down to the full thickness of the skin and soft tissue to the underlying fascia and margins were marked with two different color sutures.
While awaiting the frozen section report, the skin surrounding the area going down to the neck was undermined in this plane above the fascia to release and advanced.
The advancement was carried in multiple layers of interrupted inverted simple sutures of 5-0 PDS for the soft tissue and deep dermis. All margins free of tumor. the final closure was with running intracuticular sutures of 5-0 nylon followed by Dermabond.
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