Professional Documents
Culture Documents
4 A patient with multiple healed scars requests they be removed and repaired for cosmetic
reasons. The defects include a 100-cm2 scar of the right cheek and a 200-cm2 defect of the left
upper chest. Several split-thickness skin grafts totaling 300 cm 2 are harvested from the left and
right thighs. The scar tissue is cut away, and the sites are prepared for grafting.
Cheek graft: ____________________
Upper chest graft: ____________________, ____________________
Site prep, cheek, 100 cm2: ____________________
Site prep, chest, 200 cm2: ____________________, ____________________
5 The patient had a 20-cm2 defect of the right cheek that was repaired with a rotation flap (adjacent
tissue transfer).
CPT Code: ____________________
6 The patient had a 10-cm2 malignant neoplasm removed from the forehead. Z-plasty was used to
repair this site. How would the excision and repair be coded?
CPT Code: ____________________
7 A patient has had a portion of his mandible removed due to excision of a malignant tumor. Repair
of the site is now performed by use of a myocutaneous flap graft.
CPT Code: ____________________
8 A patient incurs second- and third-degree burns of the abdomen and thigh (10%) when she pulls
a pan of boiling water off the stove. She requires daily debridements or dressing changes for the
first week (Monday through Friday, 35). She is in severe pain and requires anesthesia during
these treatments. During the following 2 weeks she will be receiving dressing changes every
other day (Monday, Wednesday, Friday, 36), and it is expected that enough healing will have
taken place that anesthesia will not be necessary. What codes would be reported for services
during the 3-week treatment period?
Week 1 CPT Code: ____________________
Weeks 2 and 3 CPT Code: ____________________
LOCATION:, Hospital
PATIENT:
SURGEON:
PREOPERATIVE DIAGNOSIS: Lesions, left lower extremity
POSTOPERATIVE DIAGNOSIS: Undetermined lesion, right lower extremity, most likely benign with clear
margins.
SURGICAL FINDINGS: There was a 2-cm (centimeter) diameter, raised erythematous lesion with a central pore
of keratin. (This is keratosis.) Frozen section showed clear margins. Although it essentially looked benign, there
is some question of well-differentiated squamous cell carcinoma, and this is reserved as a possible diagnosis.
SURGICAL PROCEDURE: Excision of lesion, left lower extremity
ANESTHESIA: Spinal
DESCRIPTION OF PROCEDURE: Under satisfactory spinal anesthesia, the patients left leg was prepped with
Betadine scrub and solution and draped in a routine sterile fashion. The lesion was excised with a 1-cm margin
laterally and with a 2-cm margin proximally and distally tagging the superomedial aspect with a silk suture.
Dissection was carried down to the deep layer of fascia, and bleeding was electrocoagulated. One 2-0 Monocryl
suture was used subcuticularly to take tension off the wound, and then the skin was closed with interrupted
vertical mattress sutures of 3-0 Prolene. We submitted the specimen for frozen section, and the frozen-section
diagnosis was probably benign with the possibility of well-differentiated squamous cell carcinoma. The pathology
report leaned in favor of this being a benign lesion; however, we went well around the lesion. I returned to the
operating room, rescrubbed, and regloved and placed a Xeroform dressing, Kerlix fluffs over the wound, and
Kerlix fluffs around the malleoli on the heels, wrapping the foot and leg from the foot to the knee with a Kerlix roll
times two, Kling times two, and two Sof-Rol. The patient tolerated the procedure well and left the operating room
in good condition