Terry Posted Fri 03rd of August, 2012 22:27:38 PM
Help Supercoder! How would I code for a triangular excision of 3 separate lesions each with a different dx: BCC, SCC, AK. See HPI below. One surgical excision was done for all 3 lesions. Could I code three separate excisions each with their respective dx codes? See procedure note details below.
HPI - Pt was last seen 6 weeks ago at which time Biopsy by Shave Method was performed. The pathology shows: Hypertrophic Actinic Keratosis on the right lateral eyebrow, superior. The right lateral eyebrow, inferior pathology shows: Squamous Cell Carcinoma in situ. The right lateral eyebrow, middle shows: BCC-s/n.
Procedure Note: ....A fusiform excision was performed with a 15 blade on the right lateral eyebrow to the layer of subcutaneous fat/fascia. The size of the lesion was 1.7 cm and the margins were 0.2 cm for a total size of 2.1 cm. Hemostasis was achieved with pressure. Intermediate layered repair was performed to preserve normal anatomy and to reduce tension to skin to allow closure. The dermal sutures were 5-0 Vicryl. Epidermal closure was achieved with 6-0 Prolene (running). The final wound length was 3.8 cm.
SuperCoder Answered Fri 03rd of August, 2012 22:36:43 PM
I would go with 21012 for this.Lesions are on the eyebrow which needs the coding from face region. Report all three diagnosis with this code.