what cpt code to use for this procedure
Excision-Simple Repair:
Location(s): left upper back
Diagnosis/Indication: squamous or basal cell cancer
Pre-op Size: .7cm
Margins taken: .2cm
Excision size: 1cm
Post Surgical Defect Size: 1.5cm
Risks, benefits, and alternatives were discussed with the patient. We discussed possible complications including infection, bleeding, allergic reaction, nerve damage and scarring. Closure options (second intention healing, complex linear closure, skin flaps, grafts, etc.) and the need to submit the specimen to pathology were discussed. All questions answered and patient verbalized understanding. The patient is aware that if the histology reveals a tumor of more aggressive nature or inadequate margins, further treatment may be needed. Patient would like to proceed with excision and repair today. Informed consent was obtained prior to the procedure.
Preparation:
Site was confirmed by
Patient verified surgical site: Yes.
A sterile marking pen was used to draw the proposed procedure and closure. The operative field was prepped with alcohol. The skin surrounding the lesion was infiltrated with a total of 5 mLs 1% lidocaine with epinephrine. Hemostasis was achieved with pressure. Epidermal approximation was performed using 7, Epidermal approximation was performed using 2, 5-0 chromic gut sutures simple interrupted technique.
Sent to Pathology: The specimen was sent to pathology.
Final End Length: 1.5cm
Dressing: Bacitracin and a sterile pressure dressing were applied to the wound. Patient was instructed to leave it on for 24-48 hours, and post operative wound care instructions were reviewed extensively and written instructions were given. The patient voiced understanding. Estimated blood loss minimal None Patient was discharged home in good condition. Signs of wound infection discussed with patient (redness, tenderness, warm to the touch, fever greater than 101F, chills, discharge or swelling) and advised they call the office immediately if any of these symptoms occur.
Patient was given an appointment to return to clinic for suture removal and wound check .
