Tanesha Butler
Member
Can someone help with this OP note? Thanks so much! Any help is appreciated.
I have an op note where the physician excises two squamous cell lesions on the scalp. The physician then debrides the bone in order to place Integra dressing. Do I code the just the 15275 alone without the lesion excision codes? Do I need the wound prep code of 15004?
POSTOPERATIVE DIAGNOSIS: Two areas of squamous cell cancer, probable
scalp.
PROCEDURE PERFORMED:
1. Excision of a 4 x 4 centimeter lesion on the anterior part of the scalp
with debridement down to the bone and placement of double Integra layer
measuring 5 x 5 centimeters each.
2. Excision of a lesion in the posterior scalp measuring 2.0 centimeters
with debridement down to the bone and placement of a 3 x 3 centimeter
double layer of Integra.
INDICATIONS AS FOLLOWS: The patient is a 79-year-old male who has 2 very
large lesions of squamous cell cancer located on top of his head. The
patient understands that this is at least a two-step procedure to the
reconstruction of this cancer and all the risks, complications and benefits
have been explained to him fully.
PROCEDURE AS FOLLOWS: After informed consent was obtained, the patient was
placed in the OR table in supine position. IV sedation was given and
subsequent endotracheal intubation was performed. The scalp was prepped
and draped in the usual sterile fashion. A solution of half Marcaine and
half lidocaine was used to anesthetize both of the lesions. A 15 blade was
used to remove both specimens, they were then marked accordingly for a
frozen section and passed off to pathology. After confirmation of both
lesions were negative, I then proceeded to debride the bone with a power
tool in order to allow for better vascularization of the Integra dressing.
Two 5 x 5 centimeter pieces were cut out and the bottom layer was placed
with the silicone layer removed. The top layer was then also placed
directly on top of the bottom one and the _____ layer was left intact.
That was secured using a 4-0 chromic in a circumferential fashion around
the perimeter of the lesion. The same was repeated for the posterior
smaller lesion. A tight sterile dressing was then applied to allow for
compression of the Integra against the scalp. The patient tolerated the
procedure well. There were no complications, was transferred to recovery
in stable condition.
I have an op note where the physician excises two squamous cell lesions on the scalp. The physician then debrides the bone in order to place Integra dressing. Do I code the just the 15275 alone without the lesion excision codes? Do I need the wound prep code of 15004?
POSTOPERATIVE DIAGNOSIS: Two areas of squamous cell cancer, probable
scalp.
PROCEDURE PERFORMED:
1. Excision of a 4 x 4 centimeter lesion on the anterior part of the scalp
with debridement down to the bone and placement of double Integra layer
measuring 5 x 5 centimeters each.
2. Excision of a lesion in the posterior scalp measuring 2.0 centimeters
with debridement down to the bone and placement of a 3 x 3 centimeter
double layer of Integra.
INDICATIONS AS FOLLOWS: The patient is a 79-year-old male who has 2 very
large lesions of squamous cell cancer located on top of his head. The
patient understands that this is at least a two-step procedure to the
reconstruction of this cancer and all the risks, complications and benefits
have been explained to him fully.
PROCEDURE AS FOLLOWS: After informed consent was obtained, the patient was
placed in the OR table in supine position. IV sedation was given and
subsequent endotracheal intubation was performed. The scalp was prepped
and draped in the usual sterile fashion. A solution of half Marcaine and
half lidocaine was used to anesthetize both of the lesions. A 15 blade was
used to remove both specimens, they were then marked accordingly for a
frozen section and passed off to pathology. After confirmation of both
lesions were negative, I then proceeded to debride the bone with a power
tool in order to allow for better vascularization of the Integra dressing.
Two 5 x 5 centimeter pieces were cut out and the bottom layer was placed
with the silicone layer removed. The top layer was then also placed
directly on top of the bottom one and the _____ layer was left intact.
That was secured using a 4-0 chromic in a circumferential fashion around
the perimeter of the lesion. The same was repeated for the posterior
smaller lesion. A tight sterile dressing was then applied to allow for
compression of the Integra against the scalp. The patient tolerated the
procedure well. There were no complications, was transferred to recovery
in stable condition.