Results 1 to 3 of 3

how would you code this scenario????

  1. #1
    Default how would you code this scenario????
    Exam Training Packages
    I would like more feedback for this scenario
    biopsy for the face came back as actinic keratosis:

    coder 1 (14300 + 11441) after reading of path report.

    coder 2 (67961 +14060 +11310) without reading of path report


    PREOPERATIVE DIAGNOSIS:
    • Basal cell carcinoma of the left lower lid.
    • Lesions of uncertain behavior, right forehead and left cheek.

    POSTOPERATIVE DIAGNOSIS: Same.

    PROCEDURE: Unusually complicated excision and reconstruction of left lower lid.

    INDICATIONS: This is an otherwise healthy 83-year-old male who has had a history of multiple skin cancers. He had developed an ulcerative lesion measuring over 0.5 cm with irregular margins on the left lower lid. He also had keratotic lesions on his right forehead and left cheek, measuring about 1.5 cm. He was taken to the Operating Room for wide excision of the basal cell carcinoma of the left lower lid and reconstruction with flaps and/or grafts, under frozen section control, with permanent biopsies of the forehead and left cheek.

    PROCEDURE IN DETAIL: The patient's face was prepped and draped in the usual manner utilizing Betadine soap and solution. The lesion on the left lower lid was then drawn out in a diamond pattern. The area was infiltrated with 1% Xylocaine with epinephrine and a period of ten minutes was allowed for the hemostatic effects as evidenced by blanching. The lesion was then excised en bloc. A suture was placed at the 12 o'clock position. However, it became evidence that there was suspicious tissue in the underlying margin of the wound. The base of the wound was then trimmed in the suspicious area, and this was sent with the first specimen. Though labeled as one specimen, they were individually frozen and examined. This came back as the margins clear on the original specimen, but the base was positive in the secondary specimen of Specimen #1, loaded with basal cell carcinoma. At this point, we were into the muscle. A secondary 100% margin of the wound was then made. With unusually complicated, meticulous dissection, the entire base of the wound, contiguous with the 360° margins was painstakingly dissected free, trying to preserve as much of the underlying structures as possible. Meticulous hemostasis was achieved with electrocautery, and this was done with loop magnification. Eventually, the entire wound, with its new margins, was excised en bloc, and a suture placed at the 12 o'clock position. The specimen was sent to frozen section and came back with residual tumor, but margins positive, both deep and peripheral. At this point, we were left with one-third of the eyelid missing. A large Limberg transposition flap was then designed on the cheek to be rotated and brought up into the defect. The flap was marked and infiltrated. It was then mobilized with blunt and sharp dissection. It was evident that there would still be some ectropion. Then, soft tissue expansion was progressively performed until there was enough laxity to lay in the flap without pulling or distorting the eyelid. Meticulous hemostasis was achieved with electrocautery. The wound was irrigated with a clindamycin-gentamicin solution. The donor site was then undermined and advanced for primary closure. This as repaired with interrupted 6-0 Prolene sutures, mattress sutures, to take up the tension on the deep tissues. The flap was then thinned out toward the top and rotated into the defect. This was meticulously repaired with interrupted 6-0 Prolene sutures until the entire wound was closed primarily without any ectropion. Benzoin and Steri-Strips were applied, as the wound was stented.

    Attention was then turned to the other lesions, which were tangentially excised down to a punctate bleeding base and sent to Pathology, labeled right forehead and left cheek.


    Numerous other keratotic lesions in the face were then scraped down and treated with antibiotic solution.

    The patient tolerated the procedure well and left the Operating Room in stable condition.





    NoRaX

  2. #2
    Location
    Bradenton, Fl
    Posts
    82
    Default
    Quote Originally Posted by NELENAZ View Post
    I would like more feedback for this scenario
    biopsy for the face came back as actinic keratosis:

    coder 1 (14300 + 11441) after reading of path report.

    coder 2 (67961 +14060 +11310) without reading of path report


    PREOPERATIVE DIAGNOSIS:
    • Basal cell carcinoma of the left lower lid.
    • Lesions of uncertain behavior, right forehead and left cheek.

    POSTOPERATIVE DIAGNOSIS: Same.

    PROCEDURE: Unusually complicated excision and reconstruction of left lower lid.

    INDICATIONS: This is an otherwise healthy 83-year-old male who has had a history of multiple skin cancers. He had developed an ulcerative lesion measuring over 0.5 cm with irregular margins on the left lower lid. He also had keratotic lesions on his right forehead and left cheek, measuring about 1.5 cm. He was taken to the Operating Room for wide excision of the basal cell carcinoma of the left lower lid and reconstruction with flaps and/or grafts, under frozen section control, with permanent biopsies of the forehead and left cheek.

    PROCEDURE IN DETAIL: The patient's face was prepped and draped in the usual manner utilizing Betadine soap and solution. The lesion on the left lower lid was then drawn out in a diamond pattern. The area was infiltrated with 1% Xylocaine with epinephrine and a period of ten minutes was allowed for the hemostatic effects as evidenced by blanching. The lesion was then excised en bloc. A suture was placed at the 12 o'clock position. However, it became evidence that there was suspicious tissue in the underlying margin of the wound. The base of the wound was then trimmed in the suspicious area, and this was sent with the first specimen. Though labeled as one specimen, they were individually frozen and examined. This came back as the margins clear on the original specimen, but the base was positive in the secondary specimen of Specimen #1, loaded with basal cell carcinoma. At this point, we were into the muscle. A secondary 100% margin of the wound was then made. With unusually complicated, meticulous dissection, the entire base of the wound, contiguous with the 360° margins was painstakingly dissected free, trying to preserve as much of the underlying structures as possible. Meticulous hemostasis was achieved with electrocautery, and this was done with loop magnification. Eventually, the entire wound, with its new margins, was excised en bloc, and a suture placed at the 12 o'clock position. The specimen was sent to frozen section and came back with residual tumor, but margins positive, both deep and peripheral. At this point, we were left with one-third of the eyelid missing. A large Limberg transposition flap was then designed on the cheek to be rotated and brought up into the defect. The flap was marked and infiltrated. It was then mobilized with blunt and sharp dissection. It was evident that there would still be some ectropion. Then, soft tissue expansion was progressively performed until there was enough laxity to lay in the flap without pulling or distorting the eyelid. Meticulous hemostasis was achieved with electrocautery. The wound was irrigated with a clindamycin-gentamicin solution. The donor site was then undermined and advanced for primary closure. This as repaired with interrupted 6-0 Prolene sutures, mattress sutures, to take up the tension on the deep tissues. The flap was then thinned out toward the top and rotated into the defect. This was meticulously repaired with interrupted 6-0 Prolene sutures until the entire wound was closed primarily without any ectropion. Benzoin and Steri-Strips were applied, as the wound was stented.

    Attention was then turned to the other lesions, which were tangentially excised down to a punctate bleeding base and sent to Pathology, labeled right forehead and left cheek.


    Numerous other keratotic lesions in the face were then scraped down and treated with antibiotic solution.

    The patient tolerated the procedure well and left the Operating Room in stable condition.




    I agree with the 67961 because it was cut so deep into the eye lid margin. If it didn't go so deep and just involved the skin it would be coded from the integumentary section.

    I don't agree with coding the 67961 and the 14060 together, they are the same thing ones for deep and ones for skin, they are both excision and repair codes.

    Lesions are coded separately so you need one code for the cheek and one for the forehead. Was the 1.5 for them together or were each 1.5, which ever it is just code 113XX for what ever the size is for each lesion.

    That's what I see, hope it helps.
    Angie Olson, CPC

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default Don't forget modifiers!
    I'd still use 14300 as it was specifically done for a malignant lesion. (14300 carries a higher RVU that 67961)

    Two lesions were removed from face - forehead and cheek. Lesions are coded per lesion, not cumulative. But there is no precuse idea of size of each lesion ... is 1.5cm for both,combined, or for each lesion? (maybe the path report will give you a clue). In any case I'd use 1144x as appropriate for each of the lesions. (You might want to coach your physician about this as he may be leaving money on the table by not reporting the size - before excision - of each lesion individually.)

    Is coder 2 using 11310 for the "numerous other ...lesions...were scraped down..."? Again, the documentation isn't very clear.

    And don't forget your -59 modifier ... since all procedures were on the face, you'll likely get a global or duplicate edit without it.

    F Tessa Bartels, CPC, CPC-E/M
    Last edited by FTessaBartels; 09-17-2008 at 11:52 AM.

Similar Threads

  1. Code the scenario: Capture the primary diagnosis code only
    By Ally718 in forum Diagnosis Coding
    Replies: 1
    Last Post: 09-22-2015, 09:41 AM
  2. How do I code this scenario?
    By rhaney1033 in forum AAPC Coding Challenge
    Replies: 0
    Last Post: 03-26-2015, 10:30 AM
  3. E/M Code Scenario
    By Partha in forum E/M
    Replies: 2
    Last Post: 02-23-2010, 12:27 PM
  4. How would you code scenario?
    By Partha in forum E/M
    Replies: 3
    Last Post: 11-23-2009, 07:35 AM
  5. Code this scenario please:
    By Partha in forum E/M
    Replies: 6
    Last Post: 07-23-2009, 12:20 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.