AAPC CPC Exam - Topic 3 Question 34 Discussion

View MR 001394

MR 001394

Operative Report

Procedure: Excision of 11 cm back lesion with rotation flap repair.

Preoperative Diagnosis: Basal cell carcinoma

Postoperative Diagnosis: Same

Anesthesia: 1% Xylocaine solution with epinephrine warmed and buffered and injected slowly through a 30-gauge needle for the patient's comfort.

Location: Back

Size of Excision: 11 cm

Estimated Blood Loss: Minimal

Complications: None

Specimen: Sent to the lab in saline for frozen section margin control.

Procedure: The patient was taken to our surgical suite, placed in a comfortable position, prepped and draped, and locally anesthetized in the usual sterile fashion. A #15 scalpel blade was used to excise the basal cell carcinoma plus a margin of normal skin in a circular fashion in the natural relaxed skin tension lines as much as possible The lesion was removed full thickness including epidermis, dermis, and partial thickness subcutaneous tissues. The wound was then spot electro desiccated for hemorrhage control. The specimen was sent to the lab on saline for frozen section.

Rotation flap repair of defect created by foil thickness frozen section excision of basal cell carcinoma of the back. We were able to devise a 12 sq cm flap and advance it using rotation flap closure technique. This will prevent infection, dehiscence, and help reconstruct the area to approximate the situation as it was prior to surgical excision diminishing the risk of significant pain and distortion of the anatomy in the are

a. This was advanced medially to close the defect with 5 0 Vicryl and 6-0 Prolene stitches.

What CPT coding is reported for this case?