Intravenous sedation with topical anesthesia was used. Electrocautery was used to a pinpoint cautery to actualy cut around the conjunctiva into the conjunctiva where the tumor had not gorwn. This was used to cur down to the sclera and then used as electrocautery on the sclera. As the surgeon was pulling up on the conjunctiva that was connected to the tumor, the entire tumor peeled off the cornea with the corneal epithelium coming off as well. The tumor was not attached to the stroma of the cornea. This was placed in formalin and sent to pathology. Then a 3-4 mm rim of conjunctiva and Tenon's capsule was removed with a Westcott scissors and 0.12 forceps as an additional guarantee to get any malignant cells from the surgical field. This was then placed in formalin and marked as additional tissue removed adjacent to tumor site. Using a cryoprobbe, a freeze-thaw technique for approximately 30 seconds of freezing and 30 second of thawing was done twice in each spot as per standard protocal to kill any malignancy cellsthat may remain behind....... I was looking at CPT code 65400? What would you have for diagnosis codes? Any help is greatly appreciated.
Path report:
Skin lesion from limbus of left eye
High grade squamous cell dyplasia/squamous cell carcinoma in situ with marked inflammation
The dysplasia extends to one of the peripheral margins of the specimen
Lateral tumor margin left eye:
Acute inflammation in benign squamous mucosa.
reactive epithelial atypia is present but no dysplasia is seen.
