Vol. 12 •Issue 8 • Page 8
Coding Corner
Case Studies: Integumentary System Procedures
Case Study One
Preoperative and Postoperative Diagnoses: 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 percent 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.
ICD-9-CM Code Assignment
Preoperative and Postoperative Diagnosis and Code Assigned: Basal cell carcinoma, left nose and cheek.
173.3 Malignant neoplasm of skin of other and unspecified parts of face.
CPT Code Assignment
The surgeon excised the malignant lesion from the patient’s nose/face and repaired the defect with an advancement flap from the cheek. Per the coding guidelines in the CPT code manual, adjacent tissue transfer/rearrangement includes the excision of the malignant lesion.
Look for the terms Tissue, Transfer, Adjacent, Skin in the CPT manual index.
The code range 14000 Ð 14350 is listed. After reviewing the descriptions, you will see that the correct code is 14060, which should be assigned for both the facility and professional services.
14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less.
Case Study Two
Preoperative and Postoperative Diagnoses: Basal cell carcinoma, left pinna.
Procedure Performed: Excision, basal cell carcinoma, left ear 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 sides.
The lesion was peeled off with the surrounding skin all the way down to the perichondrium. This was sent for frozen section, which 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. 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.
ICD-9-CM Code Assignment
Preoperative and Postoperative Diagnoses and Code Assigned: Basal cell carcinoma, left pinna.
173.2 Malignant neoplasm of skin of ear and external auditory canal.
CPT Code Assignments
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, Skin, Malignant.
After reviewing the descriptions of the codes in the range listed (11600 – 11646), you will see the correct site and size of the lesion removed is contained in 11642.
The excision site was then repaired with a full-thickness graft from the neck. In choosing the CPT code to report 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.
After reading the descriptions of the codes listed (15200 – 15261), you will see that the correct code is 15260. This code description also states that the direct closure of the donor site is included.
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.
For facilities, assign these codes:
11642 Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion 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.
For professional services, assign these codes:
11642 Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion 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. n
Kathleen A. Mundy is a senior health care consultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.
