Medical coding. Assign both CPT and ICD-10-CM codes. PREOPERATIVE DIAGNOSIS: 1. Sebaceous cyst to the back,...
Medical coding. Assign both CPT and ICD-10-CM codes.
PREOPERATIVE DIAGNOSIS:
1. Sebaceous cyst to the back, about 1.2 cm diameter
2. Dermatofibroma right thigh, centimeter diameter
3. Dermatofibroma to the left lower leg, about centimeter diameter
POSTOPERATIVE DIAGNOSIS: Same PROCEDURE PERFORMED:
1. Excision of the sebaceous cyst of the posterior mid back, repair 1.5 cm long
2. Excision of the dermatofibroma of right thigh and left leg, repair each about 1.5 cm long
HISTORY: This 48-year-old female was seen with history of dermatofibroma to the left leg and the right leg. Recently enlarged, pigmented. Patient also has a sebaceous cyst on the back, which is irritating. Patient was taken to surgery. Under local anesthesia, the back, right leg and left thigh were prepped and draped, and the area was infiltrated 1 percent Xylocaine with epinephrine. Lesion of the back was elliptically marked, and the skin was incised, deepened to deeper fascia. The cyst was excised and sent to pathology. Skin was undermined, both superior and inferior aspect. Repair was completed with a #5-0 PDS suture and Dermabond was applied. Then the right thigh and left leg prepped and draped. Both areas infiltrated 1 percent Xylocaine with epinephrine, and the skin lesion of the right leg was elliptically excised and sent to pathology. Skin was undermined both medial and lateral aspect, and the skin was approximated. Repair was completed with a #5-0 PDS suture and Dermabond applied; and similarly, left leg skin lesion was elliptically excised and sent to pathology. Skin was advanced, and a repair was done with a #5-0 PDS suture and Dermabond was applied. Wounds dressed firmly. Patient has been transferred to recovery room fully awake and conscious.
Homework Answers
ICD-10 cm
1, sebaceous cyst L72.3
2, Dermatofibroma right thigh D23.71
3, Dermatofibroma to the left lower leg D23.72
CPT codes
1, Excision of the sebaceous cyst of the posterior mid-back, repair
1.5cm long -11402
2, Excision of the dermatofibroma of the right thigh and left leg,
repair each about 1.5cm long - 11402-59
Modifier 59 is for differentiating the procedure, it indicates
procedure was independent of other services but performed on same
day.
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Medical coding. Assign both CPT and ICD-10-CM codes.
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