Chapter 7: Practical Applications
CASE 1
PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of
forehead. (Indications for surgery.)
POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of
forehead.
OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of
forehead. (An excision with intermediate closure was performed.)
INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so,
a rapidly enlarging suspicious lesion on the right side of his forehead.
DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the table, and
was given no sedation. The area of his right forehead (Location is the right forehead.) was
draped and prepped with Betadine paint in normal sterile fashion. The area to be excised was
on the right side of the patient's mid forehead. This lesion had a maximum diameter of 1.1 cm
(Great - Answer L85.8
12052
11442-51
CASE 2
PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (postoperative and preoperative diagnosis)
POSTOPERATIVE DIAGNOSIS: Same
OPERATION Mohs micrographic surgery (Mohs surgery is performed)
Indications: The patient has a biopsy proven basal cell carcinoma on the nasal tip (Location)
measuring 8 x 7 mm.(Size) Due to its location, Mohs surgery is indicated. Mohs surgical
procedure was explained including other therapeutic options, and the inherent risks of
bleeding, scar formation, reaction to local anesthesia, cosmetic deformity, recurrence, infection,
and nerve damage. Informed consent was obtained and the patient underwent fresh tissue
Mohs surgery as follows.
, STAGE I: (Mohs surgery is performed in stages, this report indicates only one stage) The site of
the skin cancer was identified concurrently by both the patient and doctor and marked with a
surgical pen; the margins of the excision were delineated with the - Answer 17311
C44.311
CASE 3
CHIEF COMPLAINT: The patient is a 42-year-old female with infected right axillary hidradenitis.
(The diagnosis to report, and location of the hidradenitis.)
PROCEDURE NOTE: With the patient in supine position and under general anesthesia, the right
axilla was prepped and draped in the usual sterile fashion. A skin incision was made in the axilla
to excise most of the hidradenitis tracts. The incision was carried down through the
subcutaneous tissue. The underlying subcutaneous tissue was excised. (The excision went to the
subcutaneous tissue.) Bleeding points were controlled by means of electrocautery. The
subcutaneous tissues were closed in intermediate layers (The repair was intermediate.) with a
suture of 2-0 Vicryl. The skin edges were stapled together and a dry sterile dressing was applied.
The patient tolerated the procedure well.
What are the CPT® and ICD-10-CM codes reported? - Answer 11450-RT
L73.2
CASE 4
PREOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs.
POSTOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. (Postoperative diagnosis to
be used for coding)
OPERATIVE PROCEDURE: Posterior thigh suction-assisted lipectomy of posterior medial thigh,
bilateral (procedure performed).
CLINICAL NOTE:
This obese patient presents for the above procedure. She understood the potential risks and
complications including the risk of anesthesia, bleeding, infection, wound healing problems,
unfavorable scarring, and potential need for secondary surgery. She understood and desired to
proceed.
PROCEDURE:
CASE 1
PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of
forehead. (Indications for surgery.)
POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of
forehead.
OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of
forehead. (An excision with intermediate closure was performed.)
INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so,
a rapidly enlarging suspicious lesion on the right side of his forehead.
DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the table, and
was given no sedation. The area of his right forehead (Location is the right forehead.) was
draped and prepped with Betadine paint in normal sterile fashion. The area to be excised was
on the right side of the patient's mid forehead. This lesion had a maximum diameter of 1.1 cm
(Great - Answer L85.8
12052
11442-51
CASE 2
PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (postoperative and preoperative diagnosis)
POSTOPERATIVE DIAGNOSIS: Same
OPERATION Mohs micrographic surgery (Mohs surgery is performed)
Indications: The patient has a biopsy proven basal cell carcinoma on the nasal tip (Location)
measuring 8 x 7 mm.(Size) Due to its location, Mohs surgery is indicated. Mohs surgical
procedure was explained including other therapeutic options, and the inherent risks of
bleeding, scar formation, reaction to local anesthesia, cosmetic deformity, recurrence, infection,
and nerve damage. Informed consent was obtained and the patient underwent fresh tissue
Mohs surgery as follows.
, STAGE I: (Mohs surgery is performed in stages, this report indicates only one stage) The site of
the skin cancer was identified concurrently by both the patient and doctor and marked with a
surgical pen; the margins of the excision were delineated with the - Answer 17311
C44.311
CASE 3
CHIEF COMPLAINT: The patient is a 42-year-old female with infected right axillary hidradenitis.
(The diagnosis to report, and location of the hidradenitis.)
PROCEDURE NOTE: With the patient in supine position and under general anesthesia, the right
axilla was prepped and draped in the usual sterile fashion. A skin incision was made in the axilla
to excise most of the hidradenitis tracts. The incision was carried down through the
subcutaneous tissue. The underlying subcutaneous tissue was excised. (The excision went to the
subcutaneous tissue.) Bleeding points were controlled by means of electrocautery. The
subcutaneous tissues were closed in intermediate layers (The repair was intermediate.) with a
suture of 2-0 Vicryl. The skin edges were stapled together and a dry sterile dressing was applied.
The patient tolerated the procedure well.
What are the CPT® and ICD-10-CM codes reported? - Answer 11450-RT
L73.2
CASE 4
PREOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs.
POSTOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. (Postoperative diagnosis to
be used for coding)
OPERATIVE PROCEDURE: Posterior thigh suction-assisted lipectomy of posterior medial thigh,
bilateral (procedure performed).
CLINICAL NOTE:
This obese patient presents for the above procedure. She understood the potential risks and
complications including the risk of anesthesia, bleeding, infection, wound healing problems,
unfavorable scarring, and potential need for secondary surgery. She understood and desired to
proceed.
PROCEDURE:
