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Thread: Help with CPT Codes for an op note

  1. #1

    Default Help with CPT Codes for an op note

    AAPC: Back to School
    I'm looking for some assistance with these procedures, as this is not the normal coding I'm used to, These are the codes I think are accurate,
    64141, 11044, 15120, but would really love advice from other coders.
    Here is the op note...

    Diagnosis: Open complicated wound of scalp with exposed bone 2 X 2 cm,
    history of squamous cell carcinoma

    Procedures Performed: Debridement of a scalp wound doen to bone,
    Cranial Osteoplasty, Split thickness skin graft 4 sq cm to scalp/

    The scalp, debridement of the peripheral skin graft was performed undermining the graft. Using a round bur, cranial osteoplasty was sone removing the outer table of the vertex of the skul bone down to good diploe
    bleeding. It was irrigated copiously with antibiotic irrigations. Split thickness
    skin was taken from the right thigh. A 0.15-inch non-mesh was placed and sutured with 4-0 chromic and 2-0 silk suture bolster. In the donor site, 1%
    lidocaine with epinephrine was placed, 1:1000,000 as topical. Xereform was placed with an ABD and Kerlix. There were no complications in the surgery.

    Thanks in advance for any resposes,


  2. #2
    Join Date
    Apr 2007


    Did you mean 62141? It seemed to me, per your op-report, the surgeon removed a portion of the cranium due to squamous cell carcinoma of the scalp and the skull got invaded. Please check this code 61501 in addition with your 2 codes. Here is the lay description:

    The physician removes a portion of the skull bone invaded by tumor or infection. In 61500, the physician removes a tumor or bony lesion. In 61501, the physician removes infected bone. The physician incises and retracts the scalp and removes bone from the affected area. A bone graft or plastic replacement may be used to reconstruct the skull. The scalp is anastomosed and sutured in layers.

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