Please help with coding this operative report. There is a disagreement about the correct way to code this.
Procedure: Wide excision of Merkel cell skin cancer, left preauricular area of face 2.5 cm squared with layered closure.
Technique: The patient was identified, brought to the operating room placed supine on the table, given general anesthesia and intubated. The left preauricular area was prepped sterilely and draped. Time-out was completed.
Converging elliptical incisions were made longitudinally over the preauricular area of the face. The dissection was carried out in subcutaneous plane. The lesion was excised undermining was performed anteriorly over the parotid gland in the subcutaneous plane and also towards the tragus. The owund was closed in layers using interrupted 3-0 Vicryl suture and subcuticular 4-0 Monocryl suture. Sterile dressings were placed. Anesthesia was reversed. he was breathing spontaneously and extubated and brought to recovery room stable.
Thanks as always for everyones help.
I know it's been awhile - but I saw this and had some thoughts... 11643 and 12051 with 209.31 as dx.
If someone's proposing a COMPLEX closure code, keep in mind the need for documenting "extensive" undermining....just saying 'undermining was done' isn't enough to warrant a complex code, from what I've read.
And - if there's a disagreement between using integumentary codes vs. soft tissue exicison codes, - if the lesion originates in the skin, as skin cancer, I use the integumentary codes.
Hope this helps or at least prompts more opinions.
Need length of incision(s)
The documentation should also include the length of the incision(s) to correctly code this.
The incision will frequently be much larger than the lesion.
Hope that helps.
F Tessa Bartels, CPC, CEMC