Breaking Down The Report...

LOCATION: Outpatient, Hospital
PATIENT: Roger Adams
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Malignant Melanoma, mid-chest ( 1 cm )
POSTOPERATIVE DIAGNOSIS: Malignant Melanoma, mid-chest ( 1 cm )
PROCEDURE PERFORMED: Wide excision of malignant melanoma, mid-chest
PROCEDURE: The mid-chest was prepped, draped, and cleaned with Betadine solution. A margin of 2 cm laterally and medially around the lesion site was taken. The incision was carried down to the muscle fascia, which was included in the specimen. Bleeding was controlled by electrocautery, and we closed the defect with the running subcuticular 4-0 undyed Vicryl using layered closure. Steri-strips and a sterile bandage was applied. The patient tolerated the procedure well.
PATHOLOGY REPORT LATER INDICATED: Malignant melanoma
1.) What is the main term that you will look for in the alphabetical index of the ICD-9-CM manual?
2.) Identify the correct diagnosis ( ICD-9-CM) code(s) for the above scenario?
3.) What is the total size of the lesion that was removed? ( HINT: according to the op report: the lesion= 1 cm, lateral margin= 2 cm, medial margin= 2 cm ).
4.) Identify what two terms you can look for in the alphabetical index of the CPT® manual to identify the correct procedure? ( HINT: one describes the procedure, one describes organ ).
5.) Identify the correct CPT® procedure code(s) for the above scenario? ( HINT: 2 codes and last code has a modifier )