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new coder needs help with CPT/lesion excision

  1. #1
    Default new coder needs help with CPT/lesion excision
    Medical Coding Books
    Need help with CPT

    procedure: excision of left face basal cell carcinoma.
    Lesion diameter. 2x3 centimeters.
    Excised diameter: 2 1/2 x 7 0.5 centimeters.

    Op note reads: The lesion was measured and the margins were marked. The planned excision site was marked and a diamond shaped incision was made around the lesion through the full thickness of the skin to underlying healthy appearing subcutaneous fatty tissue. The lesion was fully excised with sharp and cautery dissection and marked with a single short suture in the superior margin and a double long sture at the lateral margin. It was passed off the field for frozen and permanent pathology. Bleeding points within the subcutaneous tissue were controlled with electrocautery as needed. The skin was undermined superiorly and interiorly and the wound was reapproximated with multiple deep dermal sutures of 4-0 Vicryl followed by a running subcuticular suture of 4-0 Monocryl. The wound ws clean, dry and dressed with Mastisol and Steri-Strips followed by sterile gauze and Tegaderm

  2. #2
    Fayetteville, NC
    My first question is do you have a pathology report that states that this lesion was indeed basal cell carcinoma?
    If you do then in my opinion I would code it:
    11646 and 12053-51 for the closure ( as it appears to me that the physician performed a layered closure).
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

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