Forum - Questions & Answers

Sep 28th, 2015 - mw0234

Low grade malignant trichilemmal proliferating cyst

How would an excision of this be coded?


DIAGNOSIS: 2cm right posterior scalp cyst

PROCEDURE: Excision of the above with 2 mm margins

OPERATIVE PROCEDURE:
The patient was brought to the procedure room and the above area was sterilely prepped and draped. 1% lidocaine with epinephrine was used as local anesthesia. A transverse elliptical incision was made and the above lesion was removed without difficulty. 3 0 nylon suture was used to approximate the wound in an interrupted fashion.

INSTRUCTIONS: Local wound care

PLAN: return to clinic in 2 weeks

Pathology report:

Low grade malignant trichilemmal proliferating cyst, incompletely excised

Thanks



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