- The patient is seen in follow-up for excision of the basal cell carcinoma of his nose. I examined his nose noting the wound has healed well. His pathology showed the margins were clear. He has a mass on his forehead; he says it is from a piece of sheet metal from an injury to his forehead. He has an X-ray showing a foreign body, we have offered to remove it. After obtaining consent we proceeded. The area was infiltrated with local anesthetic. I had drawn for him how I would incise over the foreign body. He observed this in the mirror so he could understand the surgery and agree on the location. I incised a thin ellipse over the mass to give better access to it, the mass was removed. There was a capsule around this, containing what appeared to be a black-colored piece of stained metal; I felt it could potentially cause a permanent black mark on his forehead. I offered to excise the metal, he wanted me to, so I went ahead and removed the capsule with the stain and removed all the black stain. I consider this to be a complicated procedure. Hemostasis was achieved with light pressure. The wound was closed in layers using 4-0 Monocryl and 6-0 Prolene. What CPT® and ICD-10-CM codes are reported?
- The patient is here because the cyst in her chest has come to a head and is still painful even though she has been on antibiotics for a week. I offered to drain it for her. After obtaining consent, we infiltrated the area with 1 cc of 1% lidocaine with epinephrine, prepped the area with Betadine and incised opened the cyst in the relaxed skin tension lines of her chest, and removed the cystic material. There was no obvious purulence. We are going to have her clean this with a Q-tip. We will let it heal on its own and eventually excise it. I will have her come back a week from Tuesday to reschedule surgery. What CPT® and ICD-10-CM codes are reported?
- . Patient has returned to the operating room to aspirate a seroma that has developed from a surgical procedure that was performed two days ago. A 16-gauge needle is used to aspirate 600 cc of non-cloudy serosanguinous fluid. What codes are reported?
- Operative Report
PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma, scalp.
POSTOPERATIVE DIAGNOSIS: Squamous carcinoma, scalp.
PROCEDURE PERFORMED: Excision of Squamous cell carcinoma, scalp with Yin-Yang flap repair
ANESTHESIA: Local, using 4 cc of 1% lidocaine with epinephrine.
ESTIMATED BLOOD LOSS: Less than 5 cc.
SPECIMENS: Squamous cell carcinoma, scalp sutured at 12 o’clock, anterior tip
INDICATIONS FOR SURGERY: The patient is a 43-year-old white man with a biopsy-proven basosquamous cell carcinoma of his scalp measuring 2.1 cm. I marked the area for excision with gross normal margins of 4 mm and I drew my planned Yin-Yang flap closure. The patient observed these markings in two mirrors, so he can understand the surgery and agreed on the location and we proceeded.
DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The patient was placed prone, his scalp and face were prepped and draped in sterile fashion. I excised the lesion as drawn to include the galea. Hemostasis was achieved with the Bovie cautery. Pathologic analysis showed the margins to be clear. I incised the Yin-Yang flaps and elevated them with the underlying galea. Hemostasis was achieved in the donor site using Bovie cautery. The flap rotated into the defect with total measurements of 2.9 cm x 3.2 cm. The donor sites were closed and the flaps inset in layers using 4-0 Monocryl and the skin stapler. Loupe magnification was used. The patient tolerated the procedure well.
What CPT® and ICD-10-CM codes are reported?
- The patient is coming in for removal of fatty tissue of the posterior iliac crest, abdomen, and the medial and lateral thighs. Suction-assisted lipectomy was undertaken in the left posterior iliac crest area and was continued on the right and the lateral trochanteric and posterior aspect of the medial thighs. The medial right and left thighs were suctioned followed by the abdomen. The total amount infused was 2300 cc and the total amount removed was 2400 cc. The incisions were closed and a compression garment was applied. What CPT® code(s) are reported?
- Operative Report
PREOPERATIVE DIAGNOSIS: Diabetic foot ulceration.
POSTOPERATIVE DIAGNOSIS: Diabetic foot ulceration.
OPERATION PERFORMED: Debridement and split thickness autografting of left foot
ANESTHESIA: General endotracheal.
INDICATIONS FOR PROCEDURE: This patient with multiple complications from Type II diabetes has developed ulcerations which were debrided and homografted last week. The homograft is taking quite nicely; the wounds appear to be fairly clean; he is ready for autografting.
DESCRIPTION OF PROCEDURE: After informed consent the patient is brought to the operating room and placed in the supine position on the operating table. Anesthetic monitoring was instituted, internal anesthesia was induced. The left lower extremity is prepped and draped in a sterile fashion. Staples were removed and the homograft was debrided from the surface of the wounds. One wound appeared to have healed; the remaining two appeared to be relatively clean. We debrided this sharply with good bleeding in all areas. Hemostasis was achieved with pressure, Bovie cautery, and warm saline soaked sponges. With good hemostasis a donor site was then obtained on the left anterior thigh, measuring less than 100 cm2. The wounds were then grafted with a split-thickness autograft that was harvested with a patch of Brown dermatome set at 12,000 of an inch thick. This was meshed 1.5:1. The donor site was infiltrated with bupivacaine and dressed. The skin graft was then applied over the wound, measured approximately 60 cm2 in dimension on the left foot. This was secured into place with skin staples and was then dressed with Acticoat 18’s, Kerlix incorporating a catheter, and gel pad. The patient tolerated the procedure well. The right foot was redressed with skin lubricant sterile gauze and Ace wrap. Anesthesia was reversed. The patient was brought back to the ICU in satisfactory condition.
What CPT® and ICD-10-CM codes are reported?
- Operative Report
Diagnosis: Basal Cell Carcinoma
Procedure: Mohs micrographic excision of skin cancer.
Site: face left lateral canthus eyelid
Pre-operative size: 0.8 cm
Indications for surgery: Area of high recurrence, area of functional and/or cosmetic importance Discussed procedure including alternative therapy, expectations, complications, and the possibility of a larger or deeper defect than expected requiring significant reconstruction. Patient’s questions were answered.
Local anesthesia 1:1 marcaine and 1% lidocaine with epinephrine. Sterile prep and drape.
Stage 1: The clinically apparent lesion was marked out with a small rim of normal appearing tissue and excised down to subcutaneous fat level with a defect size of 1.2 cm. Hemostasis was obtained and a pressure bandage placed. The tissue was sent for slide preparation. Review of the slides show clear margins for the site.
Repair: Complex repair.
Repair of Mohs micrographic surgical defect. Wound margins were extensively undermined in order to mobilize tissue for closure. Hemostasis was achieved. Repair length 3.4 cm. Narrative: Burrows triangles removed anteriorly (medial) and posteriorly (lateral). A layered closure was performed. Multiple buried absorbable sutures were placed to re-oppose deep fat. The epidermis and dermis were re-opposed using monofilament sutures. There were no complications; the patient tolerated the procedure well. Post-procedure expectations (including discomfort management), wound care and activity restrictions were reviewed. Written Instructions with urgent contact numbers given, follow-up visit and suture removal in 3-5 days
What CPT® and ICD-10-CM codes are reported?
- PREOPERATIVE & POSTOPERATIVE DIAGNOSES:
- Back pain.
- Neck pain.
- Shoulder pain.
- Shoulder grooving
NAME OF PROCEDURE:
- Right breast reduction of 1950 g.
- Right free-nipple graft.
- Left breast reduction of 1915 g.
- Left free-nipple graft.
INDICATIONS FOR SURGERY: The patient is a 43-year-old female with macromastia and associated back pain, neck pain, shoulder pain, shoulder grooving and intertrigo. She desired a breast reduction. Because of the
extreme ptotic nature of her breasts, we felt she would need a free-nipple graft technique. In the preoperative holding area, we marked her for this free-nipple graft technique of breast reduction. The patient observed these markings so she could understand the surgery and agree on the location, and we proceeded. The patient also was morbidly obese with a body mass index of 54. Because of this, we felt she met the criteria for DVT prophylaxis, which included Lovenox injection. The patient understood this would increase her risk of bleeding. She also made it known she is a Jehovah’s Witness and refused blood products, but she did understand her risk of bleeding would significantly increase and we proceeded.
DESCRIPTION OF PROCEDURE: The patient was given 40 mg of subcutaneous Lovenox in the preoperative holding area. She was then taken to the operating room. Bilateral thigh-high TED hose, in addition to bilateral pneumatic compression stockings were used throughout the procedure. IV Ancef 1 g was given. Anesthesia was induced. Both arms were secured on padded arm boards using Kerlix rolls. A similar body bear hugger was placed. The chest and abdomen were prepped and draped in sterile fashion. I began by circumscribing around each nipple-areolar complex using a 42-mm areolar marker. On each side the free-nipple grafts were harvested. They were marked to be side specific and were stored on the back table in moistened lap sponges. Meticulous hemostasis was achieved using Bovie cautery. The tail of the apex of each breast was deepithelialized using the scalpel. I amputated the inferior portion of the breast from the right side. Again, meticulous hemostasis was achieved using the Bovie cautery. There were also large feeder vessels divided and ligated using either a medium Ligaclip or 3-0 silk tie sutures. I then moved to the left and again amputated the inferior portion of the breast. Meticulous hemostasis was achieved using the Bovie cautery. Each of these wounds were temporarily closed using the skin stapler. The patient was then sat up. I felt we had achieved a very symmetrical result. The new positions for the nipple-areolar complexes were marked with a 42-mm areolar marker and methylene blue. The patient was then placed in the supine position and the new positions for the nipple-areolar complexes were deepithelialized using the scalpel. Meticulous hemostasis was then achieved again using the Bovie cautery. The free-nipple grafts were then retrieved from the back table. They were each defatted using scissors and were placed in an onlay fashion on the appropriate side, and each was inset using 5-0 plain sutures. Vents were made in the skin graft to allow for the egress of fluid on each side. A vertical mattress suture was used, tied over a piece of Xeroform in critical areas of each of the nipple-areolar complexes. A Xeroform bolster wrapped over a mineral oil-moistened sponge was affixed to each of the nipple-areolar complexes using 5-0 nylon suture. The vertical and transverse incisions were closed using 3-0 Monocryl, both interrupted and running suture, and 5-0 Prolene. The patient tolerated the procedure well. Again, meticulous hemostasis was achieved using the Bovie cautery. She was given another 1 g of Ancef at the 2-hour mark by our anesthesiologist, and was taken to the recovery room in good condition.
What CPT® codes are reported?
- INDICATIONS FOR SURGERY: The patient is an 82-year-old white male with biopsy-proven basal cell carcinoma of his right lower eyelid and cheek laterally. I marked the area for rhomboidal excision and I drew my planned rhomboid flap. The patient observed these markings in a mirror, he understood the surgery and agreed on the location and we proceeded.
DESCRIPTION OF PROCEDURE: The area was infiltrated with local anesthetic. The face was prepped and draped in sterile fashion. I excised the lesion as drawn into the subcutaneous fat. Hemostasis was achieved using Bovie cautery. Modified Mohs analysis showed the margin to be clear. I incised the rhomboid flap as drawn and elevated the flap with a full-thickness of subcutaneous fat. Hemostasis was achieved in the donor site, the Bovie cautery was not used, hand held cautery was used. The flap was rotated into the defect. The donor site was closed and flap inset in layers using 5-0 Monocryl and 6-0 Prolene. The patient tolerated the procedure well. The total site measured 1.3 cm x 2.7 cm
What CPT® code(s) should be reported?
- Wire placement in the lower outer aspect of the right breast was done by a radiologist the day prior to this procedure. During this operative session, the surgeon created an incision through the wire track and the wire track was followed down to its entrance into breast tissue. A nodule of breast tissue was noted immediately adjacent to the wire. This entire area was excised by sharp dissection, sent to pathology and returned as a benign lesion. Bleeders were cauterized, and subcutaneous tissue was closed with 3-0 Vicryl. Skin edges were approximated with 4-0 subcuticular sutures and adhesive strips were applied. The patient left the operating room in satisfactory condition. What should be the correct code(s) for the surgeon’s services?