An 86 year-old gentleman is seen with a lesion on his forehead that he wants removed, because he deems it “unsightly.” It is a
cutaneous horn of 14 mm on his right temple area. It has been there for 6 months and does not seem to be increasing in size. The
decision was made to remove this by shave technique. He also has 6 skin tags on his right neck and three skin tags on the right
lateral chest near the axilla that he wants removed.
The risks of infection and complications were discussed in detail and the patient is aware that this is not an exhaustive list. The
patient had the opportunity to ask questions, and all questions were answered.
The areas were anesthetized with Xylocaine 1% spray and then prepped and draped. Forceps are used to grasp the lesion and a #10
scalpel is used to make a transverse incision under the cutaneous horn on the temple area. The lesion is removed and pressure is
applied until bleeding stops. Next the skin tags are removed with shave technique. Dressings are applied.
Should any problems or a new lesion develop, he is to call our office for further evaluation.
What are the CPT® and ICD-10-CM codes reported?
