Excision coding

Hi, can anyone help me code this op note? Thanks so much!!

PREOPERATIVE DIAGNOSIS: Well-differentiated squamous cell carcinoma.

POSTOPERATIVE DIAGNOSIS: Well-differentiated squamous cell carcinoma.

PROCEDURE: 1. Excision of a 2.5 cm with a 0.6 cm margin, well-differentiated squamous cell carcinoma. 2. Paramedian graft nasal reconstruction with preservation of vascular pedicle.

ASSIST: None.

ESTIMATED BLOOD LOSS: Less than 50 cc.

COMPLICATIONS: None.

PATHOLOGY: Well-differentiated adenocarcinoma fully excised with multiple frozen sections.

HISTORY: The patient presents in the outpatient clinical setting with a nasal mass. Punch biopsy notes this to be a well-differentiated squamous cell carcinoma. Surgical excision is indicated at this time due to its location, size and significant growth. The risks, alternatives, and potential complications of the procedure were explained to the family in great detail and specifically I did discuss risks of recurrence, need for further surgery, cosmetic defect, need for possible radiation therapy, chemotherapy, paresthesias, anesthesias, sensory deficits as well as potential motor deficits, particularly in the area of the forehead. They are fully agreeable and informed consent was obtained.

PROCEDURE: The patient was brought back to the surgical suite, given IV access, and general tracheal anesthesia was given. The lesion is noted to be well demarcated. 1% lidocaine with 1:100,000 epinephrine utilized for anesthesia. Utilizing a separate needle, 1% lidocaine with 1:100,000 epinephrine was localized into the forehead. The patient is then prepped and draped in normal sterile fashion. A 15 blade utilized to make a circumferential excision around the lesion noting this to be 2.5 cm in diameter. It is noted on the nasal dorsum at the supratip. Careful meticulous dissection was carried out deep until the lower lateral cartilages are identified as well as the lower lateral cartilage. Once the entire lesion has been removed in its entirety, margins are then obtained. 4 different lateral margins are obtained, 1st from the 12 to 3 o’clock position, 3 to 6 o’clock, 6 o’clock to 9 o’clock position, and 9 o’clock to the 12 o’clock position. Each is identified and tagged appropriately and each consisting of approximately 3 – 4 mm of margin. Once again, continued dissection is carried out deep and once the entire lesion has been removed from the deep aspects, then deep frozen sections are obtained. There are 4 frozen sections that are obtained at 2 o’clock position, 4 o’clock position, 8 o’clock position and 10 o’clock position. These all return as clear margins. Now that we have obtained all margins on the lateral borders and all of the margins on the deep borders in multiple regions ensuring full removal of the neoplasm, reconstructive surgery is initiated. The lesion itself was 2.5 cm and the margin is 0.6 cm leaving a total defect on the nasal dorsum of 3.1 cm in diameter. In light of the very large size, a free flap from the postauricular area would have poor viability. In light of this, a paramedian flap is subsequently utilized. It is performed on the paramedian left side on the distribution of the supratrochlear artery. It is once again localized with 1% lidocaine and 1:100,000 epinephrine. Once full hemostasis had been achieved, it is noted that at this point, there are completely new instrumentation, new needles, syringes and scalpels. The superior aspect of the forehead flap was identified. Utilized a ruler to identify the extent of the defect that is noted that will require reconstructive surgery. A 15 blade is utilized to initiate the incision from the superior aspect through the frontalis muscle. It is dissected superficial to the periosteum down to the origination of the supratrochlear artery. The defect is 1.5 cm and is dissected superiorly to the superior pedicle up to 3.2 to cover the nasal defect site. The circumference for closure of the nasal defect is 8.4 cm. Length of the forehead paramedian flap pedical with preservation of vascular pedicle is 9 cm. Once it is then appropriately measured and the graft is obtainable to be placed in the area of the defect, the donor site is subsequently closed. A careful meticulous dissection, superficial to the periosteum is subsequently performed bilaterally to the medial border of the temporalis muscle. Once this has been obtained, it appears that there will be good approximation. The galea aponeurosis is subsequently approximated with a 4-0 PDS suture in a similar interrupted fashion with very good approximation. The subdermal plane is approximated with a 4-0 Vicryl suture, and the keratinized epithelium is approximated inferiorly with a 4-0 and 5-0 nylon suture in a similar interrupted fashion and superiorly where there area slightly increased tension with a 3-0 nylon suture. The most superior aspect of the defect site is unable to be closed and will close with secondary intention. The graft is then identified. It is then placed into the donor site. A very careful and very meticulous removal of the underlying adipose tissue to allow for increased vascularity is subsequently performed with a curved Iris forceps. It is then placed into the donor site and it is a careful, meticulous placement and suturing with 3-0 and 4-0 nylon suture in a vertical mattress suture is subsequently placed. Bleeding is fully controlled and full hemostasis is noted at this point. Upon completion, there is significant improvement in the patient’s cosmesis at this time and I anticipate a full recovery over time. Iodoform gauze is placed on the graft from the origination site to the

graft location. Tincoben, Steri-Strips, and Bactroban are placed on the incision site, and a pressure dressing is placed on the nasal dorsum as well as on the forehead. The patient is then remanded back to Department of Anesthesiology for their disposition. He tolerated the procedure well and transferred to postanesthesia care in stable condition.

CPT® Code(s):

ICD-9 Code(s):

re: Excision coding

CPT: 15731, 11644-51
icd: 195.0

re: Excision coding

Thank you so very very much, I truly appreciate the help!