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Chapter 18 Integumentary System

Operative Report: 1

PREOPERATIVE DIAGNOSIS: Basal cell carcinoma left nose and cheek POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma left nose and cheek

PROCEDURE PERFORMED: Excision of basal cell carcinoma left nose and cheek with frozen section control of margins and cheek advancement flap for closure

ANESTHESIA: Local

OPERATIVE TECHNIQUE: The operation was performed under a local anesthetic. The area around the lesion, which was right in the nasal crease on the left side extending onto the left side of the nose, was injected with 1% Xylocaine with 1:100,000 epinephrine. Injection was also carried out through the nasal dorsum and down along the cheek. A section was outlined to give an adequate margin on all sides. This was then drawn in with a pen. The 2.1 cm lesion was then resected along its margin using a suture to identify each margin. The lesion was then sent to Pathology, which on frozen section showed good margins on all sides. The skin was undermined to the cheek then and a skin advancement flap was outlined. The cheek was then advanced to cover the defect. This was held in place with 5-0 undyed Vicryl subcuticular sutures. 6-0 Nylon skin sutures were placed. The patient tolerated the procedure very well and was discharged without difficulty.

PATHOLOGIC DIAGNOSIS: Lesion, left nose, excision: Basal cell carcinoma, completely excised. Focal area of dermal chronic inflammation and foreign body giant cell reaction consistent with previous biopsy site.

EXERCISE OPERATIVE 1

CPT Index/Code Range: Tissue

Transfer Adjacent

Skin . . . 14000-14350

Correct CPT Codes and Modifiers (when appropriate):

Facility: 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or

lips; defect 10 sq cm or less

Rationale for CPT Coding: The surgeon excised the malignant lesion from the patients nose/face and

repaired the defect with an advancement flap from the cheek. Per the coding guidelines in the CPT code book, adjacent tissue transfer/rearrangement includes the excision of the malignant lesion, therefore, only a CPT code from this code range is required. Look for the terms Tissue followed by Transfer Adjacent Skin. The code descriptions will lead you to the correct code of 14060.

Chapter 18 Integumentary System

Operative Report:2

|PREOPERATIVE DIAGNOSIS: Left breast mass; skin tag left axilla |

|POSTOPERATIVE DIAGNOSIS: Fibrocystic changes of left breast with fibroadenoma and focal sclerosing adenosis; squamous papilloma (skin tag)|

|PROCEDURE PERFORMED: Biopsy of left breast; removal of axillary skin tags ANESTHESIA: Attended local |

|INDICATIONS FOR PROCEDURE: This is a 41 year old woman was found to have a mass in the left breast on mammography. This was confirmed as |

|being a solid area on ultrasound and was located at about the 11 o'clock position in the left breast. She has not had previous biopsies or|

|masses nor does she have a family history of breast carcinoma. Options were discussed with the patient and it was decided to go ahead with|

|the biopsy. X-ray localization will be carried out. The risks and rationale of this wire discussed and she consented to the procedure. |

|OPERATIVE FINDINGS: The patient was found to have some fibrocystic and perhaps fibroadenomatous changes and also some lipomatous changes |

|in the breast as well. A fairly sizeable lobule of breast tissue around the area in question was excised. Also a separate nodule which was|

|noted after removal of the initial specimen was excised and this appeared possibly to be a fibroadenoma. It seemed, however, to be a bit |

|to the lateral aspect of the previous biopsy site in the upper part of the breast. She also had one larger skin tag and a couple of |

|smaller ones in the axilla and she wanted to have these removed as well and, therefore, this was done with local Xylocaine anesthesia and |

|the lesions were then clipped off and cauterized. |

|OPERATIVE TECHNIQUE: Under satisfactory local Xylocaine anesthesia, having prepped and draped the area in the usual fashion, a curved |

|incision was made central to the site of the wire placement after infiltrating 1% Xylocaine with Epinephrine into the area. The wire was |

|brought out into the wound and a lobule of breast tissue was grasped along with the wire. All of the tissue down to the end of the wire |

|and a bit beyond was excised including some area more superficial to the wire where it looked like the lesion 19125-LT, 19290-LTperhaps |

|was located. After this had been removed and hemostasis accomplished with electrocautery, there was an additional small nodule which |

|appeared to be perhaps a fibroadenoma projecting into the space of the cavity after the tissue had been excised and this additional nodule|

|was also excised 19120-LT. A J&J drain was brought out through a separate stab wound. The subcutaneous tissue was approximated with 2-0 |

|Vicryl and the skin was closed with stainless steel staples. Sponge, instrument and needle counts were correct during closure of the wound|

|and the patient tolerated the procedure without complications. 1% Xylocaine was then infiltrated at the site of the larger of the skin |

|tags and it was clipped off and the base cauterized. The additional 3 small tags were also clipped off 11200-51 and the bases cauterized |

|and the patient left the operating room in satisfactory condition and was taken to the recovery room. |

|ADDENDUM: X-ray of the tissue removed showed that the lesion in question does appear to be in the specimen initially removed. |

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|EXERCISE |

|CPT Index/Code Range: Excision |

|Breast |

|Lesion . . . . 19120-19126 |

|by Needle Localization • . . . 19125-19126 |

|Placement |

|Needle Wire |

|Breast . . . 19290-19291 |

|Removal |

|Skin Tags . . . 11200-11201 |

|Correct CPT Codes and Modifiers (when appropriate): |

|Facility: 19125-LT Excision of breast lesion identified by preoperative placement of |

|radiological marker, open; single lesion, -LT, Left side of body |

|19120-LT Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant tissue, duct lesion, nipple or areolar lesion, open,|

|male or female, one or more lesions, -LT, Left side of body |

|19290-LT Preoperative placement of needle localization wire, breast, -LT, Left side of body |

|11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to |

|and including 15 lesions |

|Professional: 19125 Excision of breast lesion identified by preoperative placement of |

|radiological marker, open; single lesion |

|19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, |

|aberrant tissue, duct lesion, nipple or areolar lesion, open, male or female, one or more lesions |

|11200- 51 Removal of skin tags, multiple fibrocutaneous tags, any area up to and including 15 lesions |

|Rationale for CPT Coding: This patient had a left breast lesion. This lesion was localized by placement of a preoperative |

|marker prior to the excision of the lesion. Look in the index for the terms Excision, Breast, Lesion and by Needle Localization. The code |

|descriptions will lead you to the correct code for the lesion excised; 19125. Assign modifier -LT, Left side to communicate the left |

|breast was the excision site. Assign 19120 for the second lesion removed from the cavity. This lesion was not identified with a |

|radiological marker. For the placement of the localization wire, look in the index for the terms Placement, Needle Wire and Breast. Since |

|only one lesion was localized, the code description will lead you to the correct code of 19290. Also assign modifier -LT, Left side to |

|this code as well. The patient also had several skin tags that were clipped and cauterized from the axillary area. Look in the index for |

|the term Removal followed by Skin Tags. Count the number of tags removed to correctly determine the code you will use; 11200. |

|For the professional coding the placement of the radiological marker is not assigned by the physician performing the excision of the |

|breast lesion. Typically it is a radiologist that places the needle localization wire. |

Integumentary System Chapter 18

Operative Report:2

EXERCISE

CPT Index/Code Range: Excision

Breast

Lesion . . . . 19120-19126

by Needle Localization • . . . 19125-19126

Placement

Needle Wire

Breast . . . 19290-19291

Removal

Skin Tags . . . 11200-11201

Correct CPT Codes and Modifiers (when appropriate):

Facility: 19125-LT Excision of breast lesion identified by preoperative placement of

radiological marker, open; single lesion, -LT, Left side of body

19120-LT Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant tissue, duct lesion, nipple or areolar lesion, open, male or female, one or more lesions, -LT, Left side of body

19290-LT Preoperative placement of needle localization wire, breast, -LT, Left side of body

11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to

and including 15 lesions

Professional: 19125 Excision of breast lesion identified by preoperative placement of

radiological marker, open; single lesion

19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor,

aberrant tissue, duct lesion, nipple or areolar lesion, open, male or female, one or more lesions

11200- 51 Removal of skin tags, multiple fibrocutaneous tags, any area up to and including 15 lesions

Rationale for CPT Coding: This patient had a left breast lesion. This lesion was localized by placement of a preoperative

marker prior to the excision of the lesion. Look in the index for the terms Excision, Breast, Lesion and by Needle Localization. The code descriptions will lead you to the correct code for the lesion excised; 19125. Assign modifier -LT, Left side to communicate the left breast was the excision site. Assign 19120 for the second lesion removed from the cavity. This lesion was not identified with a radiological marker. For the placement of the localization wire, look in the index for the terms Placement, Needle Wire and Breast. Since only one lesion was localized, the code description will lead you to the correct code of 19290. Also assign modifier -LT, Left side to this code as well. The patient also had several skin tags that were clipped and cauterized from the axillary area. Look in the index for the term Removal followed by Skin Tags. Count the number of tags removed to correctly determine the code you will use; 11200.

For the professional coding the placement of the radiological marker is not assigned by the physician performing the excision of the breast lesion. Typically it is a radiologist that places the needle localization wire.

Chapter 18 Integumentary System

Operative Report:3

PREOPERATIVE DIAGNOSIS: Basal cell carcinoma left pinna POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma left pinna

PROCEDURE PERFORMED: Excision LESION basal cell carcinoma MALIGNANT left ear11642 with reconstruction with full thickness skin graft

ANESTHESIA: Local

OPERATIVE TECHNIQUE: The left ear area was injected with 1% Xylocaine with 1:100,000 epinephrine. An excision of the 1.5 by 1.0 cm diameter lesion was made being careful to allow adequate margins on all side. The lesion was peeled off with the surrounding skin all the way down to the perichondrium. This was sent for frozen section. Frozen section revealed adequate margins on all sides; therefore, a full thickness skin graft was outlined on the neck. This was removed and used to patch the defect in the posterior portion of the pinna 15260. This was secured with 6-0 Nylon simple sutures loosely in place. The donor site was undermined and sutured primarily with 4-0 undyed Vicryl and 4-0 Nylon sutures. Fluff dressing was placed on the ear and the neck. Following this, the patient was awakened and sent to the recovery room in excellent condition without complications.

PATHOLOGICAL DIAGNOSIS: Lesion, behind left ear, excision: ulcerated basal cell carcinoma, completely excised.

EXERCISE

CPT Index/Code Range: Excision

Lesion

Skin

Malignant . . . 11600-11646

Full Thickness Graft . . . 15200-15261

Correct CPT Codes and Modifiers (when appropriate):

|Facility: |11642 Excision, malignant lesion including margins, face, ears, eyelids, |

|Professional: |nose, lips; excised diameter 1.1 to 2.0 cm |

| |15260 Full thickness graft, free, including direct closure of donor site, nose, |

| |ears, eyelids, and/or lips; 20 sq cm or less |

| |11642 Excision, malignant lesion including margins, face, ears, eyelids, |

| |nose, lips; excised diameter 1.1 to 2.0 cm |

| |15260 -51 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or |

| |lips; 20 sq cm or less, -51 multiple procedure |

Rationale for CPT Coding: The surgeon states that the lesion was excised from the ear pinna (lobe). The

lesion size was measured as 1.5 x 1.0 cm in diameter. Look in the index for the terms Excision, Lesion followed by Skin, Malignant. The descriptions of the codes will lead you to the correct site and size of the lesion removed; 11642. The site of the excision was then repaired by a full thickness graft taken from the neck. In choosing the CPT code for the full thickness graft, remember that the code must reflect the recipient site not the donor site. Look in the index for the term Full Thickness Graft. The description of the codes will lead you to the correct code of 15260. The description of the code also states that the direct closure of the donor site is included in the code. The neck wound was repaired with sutures. Do not assign a separate CPT code for the suture repair of the wound. Add modifier -51 which describes multiple procedures to the second professional code assigned.

Chapter 18 Integumentary System

Operative Report:4

PREOPERATIVE DIAGNOSIS: Lipoma of right thigh

POSTOPERATIVE DIAGNOSIS: Lipoma of right thigh

PROCEDURE PERFORMED: Excision of lipoma, right thigh

ANESTHESIA: Intravenous sedation and local 0.25% Marcaine with Epinephrine 30 cc

INDICATION FOR PROCEDURE: The patient is brought to surgery for excision of enlarging, painful visible mass of the subcutaneous tissue of the right thigh which CT scan indicated was most likely a lipoma.

OPERATIVE TECHNIQUE: With the patient in lateral decubitus under intravenous sedation the right gluteal region and hip were prepped with Betadine solution and draped for surgery, following which the area overlying the mass was infiltrated with local anesthesia. A 12 cm linear incision was made in the direction of the skin lines and the underlying mass was sharply and bluntly dissected free of the surrounding tissue and removed en bloc TOTALand was noted to be consistent in appearance with a well circumscribed 10 cm in diameter lipoma 11406. After assuring adequate hemostasis, the dead space was closed with a few buried sutures of 3-0 Vicryl and the skin was closed LAYERED 12034 using interrupted buried subcuticular sutures of 3-0 Vicryl. Dry sterile dressings were placed. The patient tolerated the procedure well and left the operative suite in satisfactory condition.

Integumentary System Chapter 18

Operative Report:4

EXERCISE

CPT Index/Code Range: Excision

Lesion

Skin

Benign . . . . 11400-11471

Repair

Wound

Intermediate . . . 12031-12057

Correct CPT Codes and Modifiers (when appropriate)

|Facility |11406 Excision, benign lesion including margins, except skin tag, trunk, |

|Professional: |arms or legs; excised diameter over 4.0 cm |

|Rationale for CPT Coding |12034 Layer closure of wounds of scalp, axillae, trunk and/or extremities |

| |(excluding hands and feet); 7.6 to 12.5 cm |

| |11406 Excision, benign lesion including margins, except skin tag, trunk, |

| |arms or legs; excised diameter over 4.0 cm |

| |12034-51 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and |

| |feet); 7.6 to 12.5 cm, -51 Multiple procedures |

| |This is a straight forward excision of the lipoma. The surgeon describes the incision and the |

| |complete excision of the lipoma. Reference the term Excision in the index followed by Lesion, Skin |

| |and Benign. The code descriptions will lead you to the correct code; 11406. The excision site was |

| |then closed in layers. Reference the term Repair followed by Wound and Intermediate. The code |

| |descriptions will lead you to the correct code; 12034. |

| |Add modifier -51 multiple procedures on the second professional code. |

Chapter 18 Integumentary System

Operative Report:5

PREOPERATIVE DIGANOSIS: Status post posterior cervical laminotomy and nerve root decompressions with dehiscence of soft tissue portion of incision

POSTOPERATIVE DIAGNOSIS: Status post posterior cervical laminotomy and nerve root decompressions with dehiscence of soft tissue portion of the incision

PROCEDURE PERFORMED: Debridement and closure of posterior cervical wound ANESTHESIA: MAC

INDICATION FOR PROCEDURE: This is an 80 year old female who recently underwent a posterior cervical laminotomy and has recovered nicely from this procedure and has gotten a good result from the surgery except that she does have a dehiscence of the soft tissue of the posterior cervical incision and returns now for debridement of the wound and a wire closure.

OPERATIVE TECHNIQUE: The patient was taken to the operating room and placed in the left lateral decubitus position. A large bore IV needle was started in her arm vein and she was given an anesthetic by the nurse anesthetist for relaxation. The posterior cervical incision was then prepped and draped in the standard fashion. It was then injected with approximately 14 cc of 1% Xylocaine without Epinephrine. A #15 knife blade was used to debride the base of the incision and a small Leksell rongeur was used to remove two of the tips of posterior cervical spinous processes COMPLEX. The wound was then irrigated with normal saline with antibiotic solution added. It was closed in a one layer closure using #26 gauge wire using red rubber tipped catheter for buttressing 13160. After the wound was closed it was then packed with some plain gauze. The wound was then dressed in standard fashion. The patient was then returned to outpatient surgery in stable condition.

Integumentary System Chapter 18

Operative Report:5

EXERCISE

CPT Index/Code Range: Repair

Wound Dehiscence

Complex 13160

Correct CPT Codes and Modifiers (when appropriate)

Facility 13160 Secondary closure of surgical wound or dehiscence, extensive

or complicated

Professional 13160 Secondary closure of surgical wound or dehiscence, extensive

or complicated

Rationale for CPT Coding: The op report describes debridement of the base of the incision and the

removal of two of the tips of the posterior cervical spinous processes. The wound was then closed with a wire and the rubber catheter for buttressing. The wound was also packed. This procedure is more intensive than just a simple closure. Reference the term Repair in the index followed by Wound Dehiscence and Complex.

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