Question

PREOPERATIVE DIAGNOSIS: Scar right parietal region.

POSTOPERATIVE DIAGNOSIS: Same.

SURGICAL FINDINGS: 3 x 1 cm elevated scar right parietal region of scalp.

SURGICAL PROCEDURE: Excision scar of scalp.

ANESTHESIA: General endotracheal anesthesia, plus 2 cc of 1% Xylocaine and 1:100,000 epinephrine.

PROCEDURE: The scalp was prepped with Betadine scrub and solution, draped in the routine sterile fashion. The lesion was anesthetized with 2 cc of 1% Xylocaine with 1:100,000 epinephrine, mostly for the epinephrine effect. After a wait of four minutes the lesion was excised, bleeding was electrocoagulated; the wound was closed with vertical mattress sutures of 3-0 Prolene. Surgicel and antibiotic ointment were applied. The patient tolerated the procedure well and left the operating room in good condition.
Pathology Report Later Indicated: Benign scar tissue of skin.

ICD 10, CPT, HCPCS needed

Answer 1

1. ICD-10-CM Diagnosis Code : L90.5

Scar conditions and fibrosis of skin. Includes Contracture of scar of skin; Contracture scar; Disfigurement due to scar; Fibrosis of injection site; Fibrosis of skin; Fibrosis of the skin.

2. CPT Code (Excision scar of Scalp) : 11420 - 11426

3. HCPCS Code (1 % Xylocaine with 1:100,000 Epinephrine​) : X6488