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Auditor says this is wrong ?

  1. #1
    Default Auditor says this is wrong ?
    Medical Coding Books
    I coded this as

    15260-full thickness skin graft
    12051-primary closure ,
    where am I wrong ?, not sure

    PROCEDURES PERFORMED: 1. Excision of previously biopsied, superficial squamous cell carcinoma of her right anterior helix and covered with a full thickness skin graft.
    2. Excision of lesion of uncertain behaviour of her left cheek 2 cm in length with a primary closure.

    OPERATIVE PROCEDURE: The patient was brought to the operating room and placed under adequate basal sedation.

    had a shaved biopsy performed of the lesion of the right anterior helix and this had proven to be a superficial squamous cell carcinoma.

    decided that wanted to have the lesion surgically removed rather than attempting topical therapy. She was marked in a preanesthetic area. had also had what appeared to be a nodular basal cell, which had origin at the left cheek and this was also marked for excision.

    was then taken to the operating room, placed under basal sedation. The ear and the cheek were both infiltrated with 1% Xylocaine with 1:100,000. The cheek lesion was elliptically excised and closed with 4-0 and 5-0 Vicryl.

    The lesion was excised on the helix and it was then submitted for frozen section. The pathologist said that she did not see any residual tumor in the specimen and the margins appeared to be clear although with severe actinic keratosis and actinic change in the skin.

    A virtually full-thickness graft was harvested from the preauricular area and placed over the ear. Soft tissue overlying the ear cartilage was prepared with 5-0 Chromic sutures and the donor site and the preauricular area was closed with 5-0 Vicryl sutures. The patient tolerated the procedure well and was sent back to the recovery room in good condition.


  2. #2
    Columbia, MO
    Without a path report you cannot code the cheek lesion excision, you do not know if it is benign or malignant. You would not code the closure as we must assume simple since it is not documented as layered. What did the auditor say?

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    auditor question the closure , surgeron insist it was layered but did not document it

  4. #4
    Quote Originally Posted by trent123 View Post
    auditor question the closure , surgeron insist it was layered but did not document it
    You cannot code for what was not documented so I would agree that the closure is included.

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