Question

The following documentation is from the health record of a patient who received outpatient surgical services.

Operative Report

Preoperative Diagnosis: Melanoma of the skin of the forehead

Postoperative Diagnosis: Same

Procedure: Excision of forehead melanoma with split-thickness skin graft

The patient was given a local IV sedation and taken to the operating room suite. The face and left thigh were prepped with pHisoHex soap. The cancer was outlined for excision. The cancer measured approximately 2.5 cm in diameter. The forehead was infiltrated with 1 percent Xylocaine with 1:1,000,000 epinephrine.

The cancer was excised and carried down to the frontalis muscle. The area of the excision measured 5 4 cm in total. A suture was placed at the 12 o’clock position. The specimen was sent to pathology for frozen section.

Attention was then turned to the skin graft. A pattern of the defect was transferred to the left anterior thigh using a new needle. A local infiltration was performed on the thigh. Using a free-hand knife, a split-thickness skin graft was harvested. The thigh was treated with Tegaderm and a wraparound Kerlix and ACE wrap. The skin graft was applied and sutured to the forehead defect with running 5-0 plain catgut.

Xeroform with cotton soaked in glycerin was sutured with 4-0 silk. A sterile dressing was applied. The patient tolerated the procedure well with no complications or blood loss.

What are the correct codes reported by the physician for this procedure performed in the hospital outpatient surgical suite?

1. C43.30, 15120

2. C43.39, 15120, 11646

3. C44.319, 15100, 11646

4. C44.309, 15004, 15120

Answer 1

ANSWER.

* Correct codes.

        * C43.39,15120,11646.

        * C43.39 - Malignant melanoma of other parts of face.

           15120 - Split thickness autograft,face.

          11646 - Excision malignant lesion including margins face ; Excised

                        diameter over 40 cm.