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Scenario Week of December 23, 2010:
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Wide Excision of Malignant Melanoma

Preoperative Diagnosis: Malignant melanoma of the left upper extremity
Postoperative Diagnosis: Malignant melanoma of the left upper extremity
Operation: Wide local excision of melanoma
Anesthesia: General endotracheal
Estimated Blood Loss: Minimal
Drains: None
Complications: None

The patient is a 62-year-old white male who underwent an excisional biopsy of a malignant melanoma 1.6 cm in diameter near the posterolateral aspect of the left upper arm.

Examination today shows a surgical scar. A margin of 1.8 cm was outlined in a radial fashion from the periphery of the scar. A full thickness excision was performed followed by undermining and primary closure.

The patient also has a small keratotic lesion on the occipital scalp for which he requested excision.

The patient was appropriately identified and placed in the supine position where general endotracheal anesthesia was induced and maintained. The left arm was positioned across the chest and supported. Betadine preparation was performed. Sterile drapes where applied.

Methylene blue was used to create an outline after measuring a 1.7 radius around the periphery of the scar. An incision was performed with a #15 blade. The full thickness of the skin and subcutaneous tissue was excised with Bovie electrocautery. Undermining was performed with the Bovie to create flaps. The subcutaneous tissue was then closed with interrupted, inverted sutures of #2-0 Vicryl.

The skin was closed with multiple vertical mattress sutures of #3-0 nylon. Excellent closure, without tension was obtained. A sterile dressing was applied.

All counts were reported as correct.

Attention was directed to the lesion on the occipital scalp. Again, Betadine prep was provided and a very small elliptical incision was fashioned and the lesion excised. The specimen was sent to pathology.

Closure was provided with a single suture of #3-0 nylon, followed by Bacitracin ointment.

It should be noted that the melanoma specimen from the arm was labeled with silk suture, the short suture marking superior aspect and long suture marking the posterolateral aspect. This material was sent to pathology.

The patient tolerated the procedure well and at its conclusion was transported to the postoperative recovery room in satisfactory condition.

Addendum: The pathology report documents that the surgical margins around the upper extremity lesion were clear, with no further indications of malignant melanoma. The scalp lesion was found to be a benign hyperkeratosis.

172.6 Malignant melanoma of skin, upper limb, including shoulder
216.4 Benign neoplasm of skin, scalp and skin of neck

172.6 Malignant melanoma of skin, upper limb, including shoulder
701.1 Keratoderma, acquired

Even though the malignant melanoma has been completely excised on the previous episode of care, the treatment provided during this procedure (a wide excision) is still considered treatment for the initial malignancy. Code 172.6 is assigned as the first-listed diagnosis, reflecting the melanoma of the upper extremity. The final pathology reported substantiates a benign hyperkeratosis for the scalp lesion, which is assigned to code 701.1 as an additional diagnosis.

86.4 Radical excision of skin lesion
86.3 Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue

In ICD-9-CM, a radical skin excision is defined as one in which the procedure involves excision of underlying or adjacent structures. The operative report indicates that the full thickness skin and subcutaneous tissues of the arm were undermined with the Bovie electrocautery to create flaps. Code 86.4 is appropriate for this excision. The scalp excision was performed locally with a small elliptical incision; code 86.3 is most appropriate.

11602-LT Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm (left side)
12032 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm
11420-59 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia, excised diameter 0.5 cm or less

Regardless of whether there was any residual malignant tissue during this wide excision, the treatment involves excision of what was considered a malignant lesion, so the malignant lesion codes should be assigned. The documentation indicates that the arm lesion was 1.6 cm in diameter; code 11602 is most appropriate. Since the repair of the excision involved more than a simple technique, multiple layers and undermining were required, so a separate code is assigned for the intermediate closure. Assign 12032 since the lesion was 1.6 cm and the margin was specified as 1.8 cm (1.6 + 1.8 = 3.4 cm). For the benign scalp lesion, assign code 11420; no specific size was documented, but it was described as small and only a very small elliptical incision was required. Modifier 59 (Distinct procedural service) is appended to code 11420 to show that this excision was for a completely separate skin lesion excision.
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