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CPT® 12052 and 11642
Would like an opinion on coding this chart note:
Procedure: The procedure was discussed with the patient including adverse events, risks, the need for stitches and a permanent scar.
The area was prepped and draped in the usual sterile fashion. 2 cc of 1% lidocaine and epinephrine was used for anesthesia. An elliptical excision was performed in the usual fashion with a #15 blade around the lesion with a 3 mm margin, extending down to the subcutaneous tissue.
Hemostasis was provided by electrocautery. Wound edges were undermined. 3 sutures of 5-0 vicryl were used to reapproximate the subcutaneous tissues. Running sutures of 6-0 prolene or ethilon were used to reapproximate the epidermis. Dog-ear deformity excised :none. The patient tolerated the procedure well. Estimated blood loss minimal.
The specimen was sent to pathology. Suture or ink tag was applied for histologic orientation: no and superiorly.
The wound was dressed with a Polysporin pressure dressing and instructions were given to the patient for daily wound care. Final wound length: 3.5 cm
Return to clinic in 7 days for suture removal and discussion of results.
The doctor used 11642 and 12052, however I would consider this a simple repair as I think intermediate repairs would include the superficial fascia, and there is no mention of that in this note. Please advise!
Thanks,
JB*
re: CPT® 12052 and 11642
Does anyone have an opinion on this chart note??