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Removal of a lesion not sure what cpt to use.

  1. Default Removal of a lesion not sure what cpt to use.
    Medical Coding Books
    Questioning what cpt to use for this procedure due to my provider using the ellman unit to remove and sent out lesion. The path report says shave so if I go that way Im coming up with 172.6/11302 or if I go with just bx 172.6/11100. Just let me know what you think. Thanks

    Primary Provider:
    CC: lesion removal Lt forearm.

    History of Present Illness:
    presents for lesion removal.

    Past Medical History:
    Reviewed history from 12/13/2010 and no changes required:
    Type II DM with neuropathy
    - s/p R carotid endarterectomy, 2010
    - diffuse disease
    - medical management advised

    Past Surgical History:
    Reviewed history from 12/13/2010 and no changes required:
    R 5th toe amputation
    L spine surgery
    R Carotid Endarterectomy, 2010

    Social History:
    Reviewed history from 04/30/2010 and no changes required:
    Married, 5 kids

    Risk Factors:

    Tobacco use: quit
    Year quit: 1969
    Pack-years: 4.5
    Passive smoke exposure: no
    HIV high-risk behavior: no
    Caffeine use: Drinks coffee 1-2 times per day.
    Alcohol use: yes
    Type: Drinks wine 1 time per month having 1-2 per occasion. Never has more than five drinks per occasion.
    Exercise: yes
    Times per week: 3-4 /wk
    Type: walking
    Seatbelt use: 100 %
    Sun Exposure: occasionally

    Family History Risk Factors:
    Family History of MI in females < 65 years old: no

    Vital Signs:

    Patient Profile: Years Old Male
    Weight: 289.2 pounds
    Temp: 96.5 degrees F tympanic
    Pulse rate: 68 / minute
    Pulse rhythm: regular
    BP sitting: 130 / 74 (right arm)
    Cuff size: large

    Vitals Entered By:
    Physical Exam

    1 cm squamous cell cancer appearing lesion on left forearm

    Impression & Recommendations:

    Problem # 1: SKIN LESION (ICD-709.9)
    Remove today. If SCC will need referral for re-excision and possibly Mohs.

    The lesion was cleansed with betadine, anesthetized with 2% Lidocaine with epi and removed with the Ellman unit utilizing a loop/shave technique without complications. Hemostasis assured, dressing applied and wound care instructions given.

    Excision of Lesion (EXCLES)

    Note: All result statuses are Final unless otherwise noted.

    ! SURG201109301621 "Result Below..."
    RESULT: Specimen Source: A. LEFT FOREARM (R)

    Ordering Physician:
    Patient Name:

    Skin, forearm, left, shave biopsy:
    - Malignant melanoma, spindle cell and desmoplastic types, present at
    inked margin.
    - Ulceration: Not identified.
    - Breslow thickness: 2.2 mm.
    - Clark level: IV.
    - Margins: Invasive melanoma extends to deep and lateral inked
    margins, hence, Breslow thickness and Clark level are provisional.
    - Lymphvascular space invasion: Not identified.
    - Perineural invasion: Not identified.
    - Tumor regression: Present, involving 50% of the lesion.
    - Lymphocytic host response: Present, brisk.
    - Pre-existing lesion: Not identified.
    - Mitoses: Greater than 1 per mm2.
    - AJCC pathologic staging: T3a NX MX.

    COMMENT: Melan-A and S-100 immunohistochemical stains are performed in
    order to assess for a desmoplastic melanoma show positive S-100 staining
    in the spindle cell component (diffusely strongly positive with
    scattered staining of ovoid cells throughout the sclerotic dermis) and
    negative staining for Melan-A with alkaline phosphatase counterstain in
    many spindled melanocytes and all the epithelioid cells within the
    sclerotic dermis. Melan-A highlights atypical junctional melanocytes.
    S-100 also highlights nerves, dendritic cells and macrophages. CD68
    immunohistochemical stain is performed in order to differentiate dermal
    macrophages from epithelioid melanocytes within the sclerotic dermis and
    is diffusely positive. An S-100 (red) and CD68 (brown) combined
    immunohistochemical stain shows scattered few S100 positive cells within
    the sclerotic component. This stain is inconclusive and hence there is
    no charge for this dual stain to the patient. The Breslow thickness
    reported measures to the deepest melanocyte of the spindle cell
    component. The Breslow thickness of the sclerotic component is 5.0 mm,
    but this may represent an area of regression.

    CLINICAL HISTORY: 709.9 (unspecified disorder of skin and subcutaneous
    tissue). Additional clinical history obtained is that the lesion has
    been present for one year and has been growing. Previous biopsy from
    this site has not been performed.


    The specimen, labeled and designated, forearm, left," is
    received in formalin and consists of a 1.0 x 0.8 x 0.6 cm, tan, rubbery,
    and pitted shave of skin that is inked and trisected. All in (A1).

    __________________________________________________ _____________________

  2. #2
    Coastal Coders
    I would go with 11302.

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