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Code This!

Scenario Week of March 18, 2011:
View Current Scenario

Operation: Excision with complex layered and intermediate closures
Preoperative diagnosis: Atypical nevus x2

Indications: The patient is a 44-year-old woman who presents with a 2 cm x 2 cm atypical nevus on the central mid back and another 0.5 cm x 0.5 cm atypical nevus on the upper central back. Based on the nature of these lesions, anatomic location, and availability for adjacent normal skin, the various therapeutic and reconstructive options along with the alternatives and risks of each procedure were discussed with the patient. An elliptical incision of the central mid back lesion was selected as the therapeutic and reconstructive procedure, which would maximally preserve both function and cosmesis, and for the following reasons: 1) wound extensively undermined to 3.5 cm x 3.5 cm, 2) multiple deep placation and layered sutures placed, and 3) wound size and tension. Excision is also recommended for the lesion of the upper central back with intermediate closure.

Procedure: Having obtained written informed consent for the procedures, the patient was taken to the operating room, placed prone on the operating table, and the central mid back lesion was identified and the borders localized. The lesion measured approximately 2 cm x 2 cm. The area was cleansed with Hibiclens and saline, sterilely draped, and local anesthesia was achieved with ½% Xylocaine and ¼% Marcaine with Epinephrine. Initial tumor debulking was performed by curettage. An elliptical excision was designed to follow the relaxed skin tension lines. The incision was made along the designed lines down to fat with surgical specimen removed and sent in formalin for pathologic examination. Hemostasis was obtained with spot electrocautery. With a margin of 3 mm, the final excision size was 2.6 cm x 2.6 cm. The area was carefully and extensively undermined using blunt Metzenbaum scissors and hemostasis was again obtained with spot electrocautery. Two standing cones were removed by triangulation. The subcutaneous and dermal planes were carefully approximated using 2 deep and 3 intradermal 3/0 Vicryl sutures. The epidermis was then carefully approximated along the length of the wound using interrupted running subcutic 4/0 PDS sutures. The wound was stressed in various directions to assess the adequacy of closure and to assess tension points. It was also determined that hemostasis was stable and no other areas of bleeding were ascertained. The wound edges were pink and viable. The wound was cleansed with hydrogen peroxide. Polysporin ointment was applied to the wound surface followed by Telfa and a pressure dressing. Blood loss was minimal and totaled less than 10 cc. The final wound length was 5 cm. Attention was then given to the lesion of the upper central back. This area was anesthetized with 1% Lidocaine and epinephrine. The area was washed with Hibiclens, rinsed with saline, and draped with sterile towels. The lesion was delineated and excised. Hemostasis was obtained by electrocoagulation. With a margin of 2 mm, the final excision size was 0.9 cm x 0.9 cm. The surgical specimen was sent in formalin for pathologic examination. In order to repair this defect while maintaining normal anatomic relations and function, intermediate linear closure was utilized. Closure was oriented so the wound was in the patient’s natural skin tension lines. Deep dermal closure was performed using intradermal 4/0 Vicryl sutures. Final cutaneous approximation was achieved with a running horizontal mattress of subcutaneous 4/0 PDS sutures. The final wound length was 1.5 cm. A sterile pressure dressing was applied and wound care instructions, with a written handout, were given. The patient tolerated the procedure well and was discharged from the dermatologic surgery center alert and ambulatory.

Addenda: Pathology report confirms that both lesions were benign.

Assign the appropriate ICD-9-CM and CPT codes for the procedure above.

ICD-9-CM code:
216.5 Benign neoplasm of the skin of trunk

Rationale:
Volume 2 of the ICD-9-CM index instructs the user to see also Neoplasm, skin, benign under the “Nevus” header. This leads the coder to the neoplasm table. Under the subterm “skin,” the back is included in the code for the trunk and the benign code is selected. This is confirmed in the tabular listing in volume 1.

CPT codes:
13101 Repair, complex, trunk; 2.6 to 7.5 cm
12031-51 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities; 2.5 cm or less
11403-51 Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 2.1 to 3.0 cm
11401-51 Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 0.6 to 1.0 cm

Rationale: CPT indicates each lesion excised should be reported separately measuring the diameter including margins. Furthermore, the diameter measurement is the same whether repaired via linear closure or reconstruction. Each lesion excision is reported separately with code 11403 for the larger lesion and 11401 for the smaller lesion. When each lesion requires a separate level of repair, they should be reported separately. A complex repair includes extensive undermining, as noted in the documentation for the first lesion and reported with 13101. Intermediate repair requires layered closure of subcutaneous tissue and dermal layers, as noted in the report for the second lesion reported with 12031. Multiple procedure rules apply thereby requiring the addition of modifier 51 to the smaller lesion and both wound closures. The highest valued procedure (13101) is reported first without a modifier. Surgical trays, A4550, are not separately reimbursed by Medicare; however, other third-party payers may cover them. Check with the specific payer to determine coverage. No CCI edits apply to this operative session.
 
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