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Certificate of Attendance

Advanced Clinic:Advancement Flaps and

Adjacent Tissue Transfer CPT Coding

February 12, 2004

_____________________________________NAME

Lolita M. Jones, RHIA, CCSPresenter

The American Health Information Management Association (AHIMA) has approved this program fortwo (2) continuing education clock hours in the External Forces content area.

Retain this certificate as evidence of participation.

Advanced Clinic Advancement Flaps and Adjacent Tissue Transfer

All CPT Codes ÷ 2003 American Medical Association* Lolita M. Jones Consulting Services i

Advanced Clinic:

Advancement Flaps and

Adjacent Tissue Transfer

Author:

Lolita M. Jones, RHIA, CCS

Lolita M. Jones Consulting Services

1921 Taylor Avenue

Fort Washington, MD 20744

(V) 301-292-8027

(FAX) 301-292-8244

Coding Training: www.hcprofessor.comE-mail: [email protected]

Distributed by HCPro, Inc.


All CPT Codes 2003 American Medical Association* Lolita M. Jones Consulting Services i

Table of Contents

Disclaimer 1

About Lolita M. Jones Consulting Services 2

Objective 7

I. Adjacent Tissue Transfer 8

Clinical Coder: Adjacent Tissue Transfer/Rearrangement 9

Exercises 14

Answer Key 47


All CPT Codes 2003 American Medical Association* Lolita M. Jones Consulting Services i

DisclaimerAdvanced Clinic: Advancement Flaps and Adjacent Tissue Transfers is designed to provide accurate andauthoritative information in regard to the subject covered. Every reasonable effort has been made to ensure theaccuracy of the information within these pages. However, the ultimate responsibility lies with the user.

Lolita M. Jones Consulting Services and staff make no representation, guarantee or warranty, express or implied,that this compilation is error-free or that the use of this publication will prevent differences of opinion or disputeswith Medicare or other third-party payers, and will bear no responsibility or liability for the results or consequencesof its use.

Physician’s Current Procedural Terminology, Fourth Edition (CPT-4) is a copyrighted coding system owned andmaintained by the American Medical Association.

Please contact Lolita M. Jones, RHIA, CCS at:(V) 301-292-8027(Fax) 301-292-8244Coding Training: www.hcprofessor.comE-mail: [email protected]

© 2004 Lolita M. Jones Consulting Services

All five-digit number Physician’s Current Procedural Terminology, Fourth Edition (CPT) codes, servicedescription, instructions and/or guidelines are � 2003 American Medical Association. All rights reserved.

All rights reserved. The author grants permission for photocopying for limited personal use or internal use of theoriginal purchaser. This consent does not extend to other kinds of copying, such as for general distribution, foradvertising or promotional purposes, for creating new collective works, or for resale.

• FLAP


All CPT Codes © 2003 American Medical Association 2

About Lolita M. Jones Consulting ServicesHOSPITAL TRAINING PROGRAMS

Coding Training: www.hcprofessor.com(V) 301-292-8027

(FAX) 301-292-8244 E-mail: [email protected]

BIOGRAPHY:

Lolita M. Jones, RHIA, CCS, is an independent consultant specializing in hospital outpatient andambulatory surgery center coding, billing, reimbursement, and operations. Ms. Jones recentlylaunched her web-based coding program at www.EZMedEd.com. She has over 15 years ofexperience in publishing, training, and auditing for the hospital outpatient and freestandingambulatory surgery center (ASC) markets. Ms. Jones has earned both the Registered HealthInformation Administrator and Certified Coding Specialist credentials from the American HealthInformation Management Association (AHIMA) in Chicago, IL. Ms. Jones resides in FortWashington, Maryland, and she has developed six (6) specialty manuals for freestandingambulatory surgery centers (ASCs) as well as comprehensive manuals for the followingambulatory payment classification (APC) training programs:

Basic CPT Outpatient Coding Clinic: This 6.5 hour program is designed for(Future/Beginning/Current) Coding Specialists, Coding Managers, Reimbursement Specialists,Compliance Auditors, Hospital-Based Clinic Managers, and ALL hospital staff responsible foroutpatient coding including emergency room, ancillary department and hospital-based clinicstaff. The contents include general guidelines, steps for coding, and official CPT guidelines forsurgical procedures that are commonly performed in the hospital outpatient setting. Exercisesbased on actual ambulatory surgery operative reports will be used to strengthen the attendees’understanding of the guidelines presented.

APC Institute: Impact on Emergency Services: This 3 hour program is designed forEmergency Department: Directors, Managers, Supervisors, and Nurses; Registration Staff,Health Information Managers, Coding Specialists, and Cast Room Technicians.The contents include APC Grouping Logic, Mapping Logic for ED Medical Visits,APCs for Emergency Department Services, Modifiers –25 and –27, Emergency Screeningwithout Treatment, Critical Care, “Clotbuster” Drugs, Tissue Adhesive Wound Closure, andDocumentation Guidelines.



APC Institute: Outpatient Compliance Action Plan: This 6.5 hour program isdesigned for Compliance Department Staff (Corporate Officers, Directors, Managers,Analysts, Auditors); Health Information Management Staff (Directors, CodingManagers/Supervisors, Coding Specialists); Risk Managers, APC Coordinators,Reimbursement Specialists, Decision Support Analysts, Outpatient Billing Supervisors,Outpatient Billing Specialists, Software Vendor Product Managers, ALL staff responsiblefor facility component outpatient coding in: Registration, Hospital-Based Clinics,Ancillary Departments, and the Emergency Department. The contents include: BriefOverview of APCs; CPT Surgery Coding Compliance; and APC Compliance Issues: site-of-service billing, reason for visits, discontinued surgery, medical visits, “limited follow-up services,” colorectal cancer screening, observation stay without recovery, criticalcare, interventional radiology, modifiers, unlisted procedure codes, units of service, UB-92 claims data, and higher level APC groups.

APC Institute: Clinical Documentation Strategies: This 6.5 hour program is designed fornursing, utilization management, case management, and other health care professionalsresponsible for health records documentation. The contents include ambulatory paymentclassification (APC)-related clinical documentation requirements and management tips for thefollowing sites of service: Emergency Room, Observation Beds/Unit, Ambulatory Surgery,Hospital-Based Outpatient Departments/Clinics, Pain Management Clinic, Series/RecurringServices, Partial Hospitalization Program, Cast Room, Ancillary Testing Areas, and UtilizationManagement.

APC Institute: Coding Guidelines for Hospitals - This 1 or 2 day program is designed for alltechnical, clinical and managerial staff responsible for facility component outpatient coding thatwill directly impact ambulatory payment classification (APC) payments. The contents include:Ambulatory Surgery Reimbursement under APCs, APC Data Reporting Requirements, MedicareHospital Outpatient Edits, Outpatient Billing Procedures and Guidelines, Ambulatory ClaimsRejection Monitors, Peer Review Ambulatory Surgery Review, Coding System Reviews, How toUse ICD-9-CM, How to Use CPT, and CPT Coding Guidelines By Body System(Integumentary, Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic andLymphatic, Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, FemaleGenital, Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).



Modifier Clinic: Hospital Outpatient Issues: This 6.5 hour program is designed for coding,reimbursement, compliance, billing, database management, ancillary, and clinic staff responsiblefor modifier programming, reporting, billing, and auditing. The contents include: ModifierReporting Requirements, Official Medicare Guidelines, Recommended Hospital Front-EndModifier Edits, Electronic/On-Line UB-92 Reporting of Modifiers, Coding and BillingAborted/Discontinued Procedures, ICD-9-CM vs. Medicare Coding Guidelines, Unsuccessful vs.Aborted/Discontinued Procedures, Documentation of Reduced/Discontinued Procedures, TestingPotential Coders, Software Encoder Modifier Edits, Interventional Radiology Procedures,Information System Upgrades, Data Quality Review, Radiology Modifier Reporting Issues,Ancillary Department Modifier Reporting for Hospitals, and Exercises/Case Studies.

APC Institute: Hospital Financial and Operational Issues: This 6.5 hour program is designedfor hospital executives, directors, chargemaster coordinators, coding/reimbursement staff, andinformation system/database managers who will implement ambulatory payment classifications(APCs). The contents include: General Overview of APCs, APC Data Reporting Requirements,APC Policy Issues, Developing a Plan of Action, Conducting Hospital-Wide APC Education,and Assessing Current Outpatient Operations for: Overall Hospital, Management InformationSystems, Business Office/Patient Accounts, Health Information Management, AncillaryDepartments/Chargemaster, Emergency Room, Hospital-Based Clinics, Hospital-OwnedSatellite Facilities, Hospital-Based Physician Coding and Billing, and Utilization Management.

APC Institute: Billing and Reimbursement Issues. This 6.5 hour program is designed forChief Financial Officers, Vice Presidents of Finance, Controllers, Chargemaster Coordinators,Database Managers, Software Vendor Product Managers, Coding Managers, ReimbursementSpecialists, Director of Patient Accounts/Business Office, Outpatient BillingSupervisor/Coordinator, Outpatient Billing Specialists. The contents include: Durable MedicalEquipment and Prosthetics, Pre-operative Registration, Outpatient Service “Red Flags,”Chargemaster/Charge Entry, Claims Preparation, Claims Payment, Tracking and ReviewingMedicare Billing Guidelines.



Lolita M. Jones Consulting ServicesFREESTANDING

AMBUALTORY SURGERY CENTERTRAINING PROGRAMS

ASC Clinic: Multi-Specialty Procedures - This 6.5 hour program is designed for Freestandingambulatory surgery center (ASC) Managers (Business, Nurse, Reimbursement), Directors,Administrators, Coding Supervisors, Coding Specialists, and Billers. The contents include:Current Freestanding ASC Structure, Proposed Freestanding ASC Structure, Medicare CodingRequirements, Medicare Billing Requirements, Coding Ambulatory Surgery, How To Use CPTWhen Coding Ambulatory Surgery, and CPT Coding Guidelines By Body System(Integumentary, Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic andLymphatic, Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, FemaleGenital, Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).

ASC Clinic: Dermatology & Plastic Surgery - This 6.5 hour program is designed for alltechnical, clinical and managerial staff responsible for facility component freestanding ASCcoding and billing. The contents include: exercises based on actual outpatient operative reports;and CPT coding guidelines for topics such as: tissue expander, pedicle flap, pressure ulcer, skingrafts, nail avulsion and excision, scar revision, burn treatment, lesion excisions, wound repair,adjacent tissue transfer/rearrangement, breast surgery, free flaps with microvascular anastomosis.

ASC Clinic: Eye & Oculoplastic Surgery - This 6.5 hour program is designed for all technical,clinical and managerial staff responsible for facility component freestanding ASC coding andbilling. The contents include: exercises based on actual outpatient operative reports; and CPTcoding guidelines for topics such as: cataracts. intraocular lens, keratoplasty, trabeculectomy,strabismus surgery, punctum plugs, tarsorrhaphy, trichiasis correction, retinal detachment repair,vitrectomy.



ASC Clinic: Gastroenterology Procedures- This 6.5 hour program is designed for all technical,clinical and managerial staff responsible for facility component freestanding ASC coding andbilling. The contents include: exercises based on actual outpatient operative reports; and CPTcoding guidelines for topics such as: hernia repair, nasogastric intubation, percutaneousgastrostomy tube, hemorrhoidectomy, abscess/cyst drainage, dental procedures, covered andnoncovered colorectal cancer screening, gastrointestinal endoscopy, esophageal dilation.

ASC Clinic: Orthopaedic Surgery - This 1 or 2 day program is designed for all technical,clinical and managerial staff responsible for facility component freestanding ASC coding andbilling. The contents include: exercises based on actual outpatient operative reports; and CPTcoding guidelines for topics such as: ganglion cyst, joint injections, decompression fasciotomy,treatment of fractures/dislocations, skeletal anatomy of the hand and foot, surgical kneearthroscopy, bunionectomy, toe-to-hand transfer with microvascular anastomosis.

ASC Clinic: Urology Procedures - This 6.5 hour program is designed for all technical, clinicaland managerial staff responsible for facility component freestanding ASC coding and billing.The contents include: exercises based on actual outpatient operative reports; and CPT codingguidelines for topics such as: retrograde pyelogram, ureter vs. urethra, urethral dilation, ureteralstent, urethral stent, Burch Procedure, vesicourethropexy/urethropexy, urodynamics,chemotherapy.



OBJECTIVE: This program will first provide a detailed review of the advancement flap andadjacent tissue transfer CPT coding guidelines to assist the participants in their understanding ofthe numerous techniques that are performed. “Real life” operative report case studies will alsobe presented for many of the adjacent tissue transfer techniques that are discussed.



I. Adjacent Tissue Transfer

14000 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less

14001 Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm

14020 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sqcm or less

14021 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sqcm to 30.0 sq cm

14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck,axillae, genitalia, hands and/or feet; defect 10 sq cm or less

14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck,axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm

14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect10 sq cm or less

14061 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect10.1 sq cm to 30.0 sq cm

14300 Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual orcomplicated, any area



Clinical Coder: Adjacent Tissue Transfer/Rearrangement

The table on the following page describes various adjacent tissue transfers orrearrangements. A surgeon may perform one of these procedures to repair large wounds orburns that are not treatable with a simple or multilayer closure technique. The surgeondecides which procedure is most appropriate based on the size, shape and location of thearea to be treated.

Many of the techniques described here are flap procedures. In these procedures, thesurgeon lifts a portion of skin and subcutaneous tissue from somewhere on the patient’sbody (donor site). A portion of this skin and tissue is immediately grafted to a new(recipient) site on the patient’s body. The remaining portion of skin and tissue (base) stayspartially connected to the donor site until sufficient blood flow and nutrition to therecipient site is established. At that point, the base can be removed and grafted to therecipient site.

Coding Tips:• All of these adjacent tissue transfer/rearrangement procedures are reported using CPT codes 14000

through 14300. If a lesion is excised and an adjacent tissue transfer or rearrangement isperformed at the same site, excision of the lesion is not reported separately (Source:CPT Assisant newsletter, July 1999, page 3). The specific code used is determined by the sizeand location of the defect site. Codes in the 14000 through 14300 range require that the coderindicate in square centimeters (sq. cm) the size of the defect site to which the adjacent tissuetransfer/rearrangement is being applied. To calculate this figure, the coder must multiply thedimensions of the original wound site (e.g., a 5 x 4 cm wound is 20 sq. cm). Never code based on thedimensions of the graft’s donor site.

• If two lesions from the same anatomical classification are removed with both of the resulting defectsrequiring adjacent tissue transfer closure, the appropriate code from the 14000-14300 series may bereported for each tissue transfer (eg, flap advancement) performed, provided the defects havedistinct margins and are not contiguous. The primary repair code should be reported as listed in theCPT manual. Modifier –59 (Distinct Procedural Service) should be appended to subsequent repaircodes to indicate that the tissue advancement was performed at a separate anatomical site.

For example, if a lesion is removed from the forehead, resulting in a 5.2 sq cm defect, andanother lesion is removed from the neck, resulting in a 7.3 sq cm defect, and both requirerotational advancement flaps to provide closure, then CPT code 14040 would be reported twice,with modifier –59 appended to the second code. Although both anatomic sites fall into the sameanatomic classification as defined by the code descriptor for code 14040, the defects do not havecontiguous margins and represent separate and distinct defects (Source: CPT Assistantnewsletter, July 2000, page 10).



Clinical Coder: Adjacent Tissue Transfer/Rearrangement – cont’d

• CPT code 14300 is reported when the physician performs an unusual or complex tissuetransfer or rearrangement. CPT does not define unusual or complicated; instead, thisdetermination is made by the physician. Code 14300 may be reported for anyanatomical area. (Source: CPT Assistant newsletter, July 1999, page 3.)

• When another graft or flap is required for closure of the donor site, this is considered anadditional procedure, and should be reported with a separate CPT code. (Source: CPTAssistant newsletter, July 1999, page 3.)

• Note that the type of procedure is not determined by the shape of the wound repair. Forexample, if the repaired wound incidentally results in the shape of a V, it should notautomatically be coded as a Y-V plasty. In order for it to be considered a Y-V plasty, thatprocedure must have been intended by the surgeon. Thus, to assign a code from the14000 through 14300 range, a tissue transfer/rearrangement must be fully performedby the surgeon.




• The term “defect,” as used for the adjacent tissue transfer codes, has had variable interpretations. Adjacent tissue transfer actually involves a primary and secondary “defect,” both of which are repaired in the adjacent tissue transfer procedure. The primary defect, by definition, is the original defect to be closed. The secondary defect is the defect created by the movement of tissue necessary to close the primary defect. Since both types of defects affect the amount of effort necessary to perform the procedure, the language included in the guidelines now reflects the true nature of the procedure performed by specifying the need to include both the primary and secondary defects as part of the measurement for this type of repair.

In addition, the “defect” and the attending physician work involve for the procedure varies more with the type of flap utilized than with the size of the lesion removed. For instance, in some cases, the primary defect may approximate the size of the secondary defect. However, in many instances, the secondary defect area must be considerably larger than the primary defect area, depending on factors such as location, skin mobility and elasticity, or adjacent structures such as lip or eyelid.

Example:

A large cheek rotation flap may be required to repair a much smaller intra- orbital defect in order to avoid downward traction on the eyelid. Significantly more work is required to mobilize a large area of the cheek for repair of a 5-sq cm primary intra-orbital defect, than to repair the same size primary defect at the angle of the jaw with a transposition flap.

[Source: CPT Changes 2004 – An Insider’s View, AMA, Chicago, IL, 2003.]




Type of TissueTransfer/Rearrangement

Brief Description of Procedure Comments (if applicable)

Z-plasty

W-plasty

Advancement flap

V-Y (or Y-V) plasty

A scar is lengthened, straightened orrealigned to help reduce tension onthe wound and, thus, produce abetter cosmetic effect.

This procedure is similar to a Z-plasty but is used for less linearscar/wound repair.

This is the simplest of all flaps—thesurgeon simply “stretches” nearbyskin over a wound.

In the V-Y procedure, an incision ismade in the shape of V and suturedin the shape of Y to lengthen an areaof tissue; conversely, a Y-V plastybegins with a Y-shaped incision thatis sutured in the shape of a V toshorten an area of tissue.

Considered atype ofadvancementflap

Rotation flap

Pedicle ordouble-pedicleflaps

A semicircular flap of skin is rotatedinto position over the wound site.

Flaps consisting of the full thicknessof the skin and the subcutaneoustissue are transferred to a cleantissue bed.

Also calledtranspositionalor interpolationflap

Ideal forcoveringexposed boneand tendon




Type of TissueTransfer/Rearrangement

Brief Description of Procedure Comments (if applicable)

Sliding flap A flap is transferred to its newposition using a sliding technique.

Similar to ad-vancement flap

Melolabial flap

Kutler procedure

A flap from the medial cheek, used asa transposition flap, to repair a defecton the side of the nose. It is used fordeep nasal defects, providing thicksebaceous skin and subcutaneous fat for rebuilding tissue lost in surgery.Folded on itself, it can recreate analar rim.

Two flaps are developed, one on eachside of the finger, which are thenmobilized toward the tip of the fingerand sutured to conform to thenormal shape of the end of the finger.This is an example of a V-Y plasty.

This flap is often erroneously referred to as “Nasolabial flap” in the medical record.



Exercise 1: Read the following operative report and answer the coding questions thatfollow.

Operative Report

Preoperative Diagnosis: Basal cell carcinoma, left ear

Postoperative Diagnosis: Same

Operation(s): Wide excision, frozen section and reconstruction byrotation flap

Description of operation: Patient was given local infiltration anesthesia of0.50% Xylocaine with epinephrine. Parts were prepped and draped in the usualfashion. The area of basal cell carcinoma, which was right behind the helicaldome, was excised. The total area of excision was about 2 cm. X 2 cm. It wasgiven to the pathologist for proper orientation, who determined that the marginswere free, and it was basal cell carcinoma indeed. A superiorly based rotation flapmeasuring 3 cm. X 1.5 cm was then marked, incised, undermined, transposedinto the defect, and closure was done with 5-0 nylon interrupted sutures. Donor sitewas closed by advancement flaps. At the conclusion of the procedure, the flapswere viable. Hemostasis was satisfactory. A bulky dressing was applied.

The patient left for home in satisfactory condition.



Exercise 1—continued

Coding Questions:

1. What was (were) the diagnostic reason(s) for the encounter/visit?

2. The basal cell carcinoma was located behind the helical dome of the left ear.a. trueb. false

3. What were the dimensions of the site from which the basal cell carcinoma wasexcised?

4. What type of adjacent tissue transfer was applied to the basal cell carcinoma defectsite?

a. pedicle flapb. sliding flapc. rotational flapd. advancement flap

5. What was the donor site for the adjacent tissue that was transferred to the basal cellcarcinoma defect site?a. superior region of the defect siteb. supraclavicular areac. rotator cuff area

6. What were the dimensions of the donor site for the rotation flap?

7. How was the donor site for the rotation flap closed?a. suture closureb. advancement flap applicationc. skin graft application




8. Rotation flap is also called?a. transpositional flapb. advancement flapc. interpolation flap

9. Please list the CPT surgery codes and modifier codes for this case:



Exercise 2: Please read the following operative and/or Pathology Report and assign theappropriate CPT codes and modifiers.

Operative Report

PREOPERATIVE DIAGNOSES1. Atypical nevus of the left shoulder.2. Enlarging mass of the left forehead.

POSTOPERATIVE DIAGNOSES1. Atypical nevus of the left shoulder.2. Enlarging mass of the left forehead.

OPERATION1. Excision of forehead mass with primary closure.2. Excision of atypical nevus with W-plasty of about 15 square centimeters.

ANESTHESIALocal anesthesia.

ESTIMATED BLOOD LOSSLess than 2 cc.

HISTORY OF PRESENT ILLNESSThis is a 47 year-old white male with a history of extensive sun exposure who haspresented in the past with atypical nevus. His previous excision of his left shoulderrevealed an atypical nevus with extension to the margins. The patient has beenrecommended for reexcision of this lesion. He also noted an enlarging new mass of hisleft forehead. The patient was recommended for re-excision of these lesions. The risksand benefits of the procedure including bleeding, infection, recurrence, need foradditional procedures were discussed and accepted by the patient. The patient hasrequested the above procedure.

PROCEDURE/FINDINGSThe patient underwent local anesthesia and was draped and prepped in the usual sterilefashion. An elliptical incision was made over the forehead to excise the mass. Primaryclosure of 3 cm was performed. The patient tolerated this half of the procedure well.The wound was closed with Vicryl followed by a nylon suture.

Attention was then directed to the back where a 3- x 5-cm elliptical incision was made.The lesion was resected. The wound was then undermined and closed using a W-plasty type of closure. It was closed with Vicryl followed by a nylon suture. At the endof the procedure, hemostasis was ensured. The patient was awakened and taken to therecovery room in stable condition. He was discharged on p.o. Tylenol and is to follow upin our office in approximately one week’s time for suture removal.




Pathology Report

Specimen: 02:SP001833Spec Type: Surgical P Subm Dr:

PREOPERATIVE DIAGNOSISNeoplasm

OPERATION PERFORMEDDate: 02/28/02Doctor(s)Procedure: Left 015 Excision lesion, left 015 excision lesion, excisiProcedure (cont): Lt forehard, excision atypical nevus, left posterior

TISSUE REMOVEDA. Lesion, Left ForeheadB. Atypical nevus, Lt Posterior Shoulder-Long Suture Tag, Superior; Short Suture Tag,

Left

GROSS DESCRIPTIONPart A: Received labeled lesion, left forehead. The specimen consists of an irregularfragment of white skin with a small amount of pink-tan subcutaneous tissue attachedmeasuring 0.7 x 0.4 cm and excised to a maximum depth of 0.3 cm. The skin surface isdiffusely vaguely nodular. The specimen is not oriented. The tips of the specimen areremoved. The resection margin of the remainder of the specimen is inked black, and theremainder of the specimen is bisected. The specimen is entirely submitted in A.

Part B: Received labeled atypical nevus, left shoulder, long-superior, short-left. Thespecimen consists of an ellipse of pink-tan, hair bearing skin with attached pink-tansubcutaneous tissue measuring 2.1 x 1.2 cm and excised to a maximum depth of 0.4 cm.The specimen has been oriented by the surgeon as previously described. Centrallylocated on the specimen is an ill-defined, irregular brown discolored area measuring 1.1 x0.7 cm. Black ink is applied to the lateral half of the resection margin, and yellow ink isapplied to the medial half. The specimen is serially sectioned from superior to inferior toreveal a grossly unremarkable white solid and homogeneous cut surface. The superiorhalf of the specimen is entirely submitted in B1, and the inferior half is submitted in B2.The smallest piece in each cassette represent the tips of the specimen.(CB/JW:KLM)

PATH PROCEDURESProcedures:

Path DSM, A1 Blk, B1 Blk, B2 Blk




FINAL DIAGNOSISPart A: Skin, Left Forehead, Biopsy: Intradermal Nevus.

Part B: :Skin, Left posterior shoulder excisional biopsy: Atypical junctional melanocytichyperplasia consistent with residual atypical nevus, completely excised. The biopsy siteconsists of dermal scarring and chronic inflammation.(JW: KLM)

REVIEWSHR

Signed____________________________________________

CPT Procedure/Modifier Code(s):__________________________________________



Exercise 3: Please read the following Operative and/or Pathology Report and assign theappropriate CPT codes and modifiers.

Operative Report

OPERATION: Re-excision of basal cell carcinoma of the forehead. Reconstruction ofdefect, 5 x 2.5 cm, with superior and inferior advancement flap closure.

ANESTHESIA: 1% Xylocaine with epinephrine and 0.5% Marcaine with epinephrine.

PREOPERATIVE DIAGNOSIS: Basal cell carcinoma of the forehead. History ofresidual basal cell carcinoma of the forehead.

POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma of the forehead. History ofresidual basal cell carcinoma of the forehead.

OPERATIVE PROCEDURE: The 57 year-old patient was seen in the preoperativeholding area and marked. He was brought to the operating room and placed in the supineposition. The above-noted anesthetic was used to infiltrate the area. Oncevasoconstriction was noted, the patient was prepped and draped in a sterile manner.Utilizing 2.5 power loupe magnification, full-thickness circumferential excision wasperformed around the previous scar. The superior margin was marked with a shortsuture and the left margin with a long suture. This was sent for frozen section.Hemostasis was achieved with electrocautery. Double hook retractors were inserted, andwith traction and countertraction, advancement flaps were elevated superiorly andinferiorly. The wound was irrigated, and reinspected for hemostasis. The pathologyreport revealed inflammatory reaction, without evidence of basal cell carcinoma.Advancement of the deep subcutaneous tissue to the midline was performed with 4-0Vicryl suture, followed by 4-0 Vicryl in the subdermal plane and running subcuticular 4-0 Monocryl. Skin prep and Steri-Strips were applied. The patient was transferred backin satisfactory condition.




Pathology Report

FINAL DIAGNOSIS:1. Skin, Forehead, Re-Excision (A) – Basal Cell Carcinoma, Micronodular Type.

-scar and healing surgical wound.2. Soft Tissue, Forehead, Deep Margin of excision (B) – Chronic Inflammation and

Fibrosis.- Negative for Neoplasm.

COMMENT: In specimen A, the residual basal cell carcinoma is completely excised.

** Report Electronically Signed Out**

************************************************************************

SPECIMEN(S) SUBMITTEDPart A: Lesion ForeheadPart B: Lesion Forehead Deep Margins

CLINICAL DATA:Lesion Forehead.

GROSS DESCRIPTION:A. Received fresh for frozen section consultation is an ellipse of skin and subcutaneous

tissue measuring 3 x 0.9 x 0.3 cm. This specimen has been oriented by the surgeonwith a long suture on the left and a short suture superiorly. A scar is seen at the centerof the ellipse. A suspicious skin lesion is not identified grossly. The superior aspectof the specimen is inked with blue ink, the inferior aspect with yellow ink and thedeep with black ink. In addition, the left tip is designated with black ink. Serial crosssections reveal scar and no evidence of residual gross neoplasm. A representativesection including both tips and two sections through the ellipse are submitted forfrozen section consultation. The remainder of the specimen is submitted in formalinin three cassettes.

B. Received in formalin are three segments of tan-pink soft irregular shaped tissueaggregating to 1.0 x 0.5 x 0.3 cm. The specimen is not sectioned. Totally submittedin formalin in one cassette.

INTRAOPERATIVE CONSULTATION:A. Margin Negative for basal cell carcinoma, biopsy repair reaction.

(Dr.)




Operative Report

PREOPERATIVE DIAGNOSIS:Basal cell carcinoma, left infraauricular area and keratosis preauricular area left.

POSTOPERATIVE DIAGNOSIS:Basal cell carcinoma, left infraauricular area and keratosis preauricular area left.

OPERATION:Excision of basal cell carcinoma measuring 3 x 2 centimeters under frozen sectioncontrol, and closure with rotation flap. Shave excision keratosis 1 centimeter leftpreauricular area.

ANESTHESIA:Local. BLOOD LOSS: Minimal.

COMPLICATIONS:None.

INDICATIONS:This 79 year-old patient presented with the above diagnosis, undergoing excision ofbasal cell carcinoma. This was an infiltrating type. The excision, pros, cons,complications were discussed. She had no evidence of metastasis. Risks of infection,bleeding, scarring, need for flap, autograft, and recurrence were discussed; so was theneed of secondary operation.

DESCRIPTION OF PROCEDURE:After prepping and draping the patient in the usual fashion with pHisoHex solution,markings were made. Anesthesia was infiltrated. After waiting a few minutes for itseffect, elliptical excision was performed. I included a 7 mm margin as this wasinfiltrating. Hemostasis was assured. Frozen section was submitted, that came back asnegative. A rotation flap was needed in order not to distort the earlobe on this patient asprimary closures which have resulted in distortion. A superiorly based flap wasoutlined, measured about 4 x 2 cm, elevated including skin and subcutaneous tissue,and rotated to the recipient bed. Closure in multiple layers with 4-0 Monocryl and 6-0Monocryl suture, and 6-0 nylon suture was done. Shave excision of the preauricularlesion was performed. The procedure was tolerated well.

COMPLICATIONS:_________________________________




PATHOLOGY REPORT

SURGICALAP Case Type: SurgicalAP Accession No. S01-12912AP Result Status FinalAP Specimen Descr Biopsy, Anterior Margin, Postauricular Left

Ear, F.S.Biopsy, Posterior Margin, Postauricular LeftEar, F.S.Main LesionLesion, Face

SPECIMEN: 1: Biopsy, Anterior margin, Postauricular left ear, F.S.2: Biopsy, Posterior margin, Postauricular left ear, F.S.3: Main Lesion4: Lesion, Face

GROSS:1. Specimen is received fresh and consists of a piece of skin measuring 1.2 x 0.2 cm.The specimen is frozen entirely and subsequently submitted entirely in a single cassette.Frozen Section Diagnosis: No tumor identified. (SS)2. Specimen is received fresh and consists of a piece of skin measuring 1.2 x 0.2 cm.The specimen is frozen entirely and subsequently submitted entirely in a single cassette.Frozen Section Diagnosis: No tumor identified. (SS)SS:klk3. Specimen is received in formalin and consists of an ellipse of tan skin with araised lesion in the center. The skin measure 2.5 x 1.5 cm. The lesion is circular andmeasures 0.4 cm and it is 0.4 cm away from the surgical cut edge. The specimen isinked. The longitudinal ends are submitted in – 1 cassette. The remainder is seriallysectioned and submitted entirely in – 4 cassettes.4. Specimen is received in formalin and consists of a shaved biopsy of karatoticappearing white skin measuring 0.6 x 0.6 x 0.1 cm. The specimen is inked and submittedentirely in a single cassette. ESS – 1 cassette.SS: rbj




DIAGNOSIS:1. Post auricular anterior margin, left ear skin with solarelastosisNo tumor identified2. Post auricular posterior margin, left ear;Skin with sun damageNo tumor identified3. Main lesion:

BASAL CELL CARCINOMAScarMargins free of tumor4. Face lesion:5. Seborrheic keratosis





Operative Note

PREOPERATIVE DIAGNOSIS:Cyst right ear.

PROCEDURE:Removal of cyst and repair with mucoperichondrial flaps.

POSTOPERATIVE DIAGNOSIS:The same.

ANESTHETIST:

ANESTHESIA:

CLINICAL NOTE:This 39 year-old female patient had a large cyst on the conchal surface of the ear whichhad been present for several years. The cyst had recently enlarged and the patient wantedit removed.

PROCEDURE:The patient was brought into the Operating Room where we proceeded to excise the cystwith an elliptical excision and then dissected around skin flaps so that we could closethe wound. Attempts to close the wound primarily failed. After having dissectedcarefully the cyst and




removed it the space was too great. We then tried bending the ear medially toward theocciput to close the wound and this pinned the ear too much into the occiput. For thisreason we decided to free up mucoperichondrial flaps. Almost the entire surface ofthe posterior ear was advanced so they could meet mastoid skin .

After having done this we set the skin with #3-0 Vicryl sutures. The skin was then closedwith a #6-0 fast absorbing catgut suture. We placed Steri-strips on the entire medial skinof the ear to splint it and to prevent any postoperative hematoma. We then placed a bulkycompressive dressing on the ear. This was turned into a mastoid dressing which thepatient will be wearing for three days.




Surgical Pathology Result Report

CLINICAL HISTORY:Right ear cyst

OPERATION: Excision

GROSS DESCRIPTION:(MKP/jlg) In formalin labeled “cyst right ear” is an ellipse of skin measuring 1.5 x

0.9 cm excised to a depth of 0.6 cm. The skin covers a 1.2 x 0.5 x 0.4 cmcyst containing light grumous material. Representative sections aresubmitted as 1A.

FINAL DIAGNOSIS:Skin lesion, right ear:

Epidermal Inclusion cyst.





Operative Report

PRE-OPERATIVE DIAGNOSIS: Surgical defect left cheek and preauricular area greaterthan 30 sq cm, status post Mohs histologic surgery for basal cell carcinoma left cheek.

POST-OPERATIVE DIAGNOSIS: Surgical defect left cheek and preauricular area greaterthan 30 sq cm, status post Mohs histologic surgery for basal cell carcinoma left cheek.

PROCEDURE PERFORMED: Complex repair left cheek greater than 30 sq cmutilizing adjacent tissue transfer (rhomboid flap).

ANESTHESIA: General endotracheal.

PROCEDURE: The patient was brought to the operating room in good condition andplaced supine on the operating table. After induction of general endotracheal anesthesia, thepatient was prepped and draped with the left side of the face superior. Analysis of thesurgical defect revealed an irregular trapezoid wound measuring 6 cm in verticaldimension x 5 cm in horizontal width. The wound was full thickness and extended to themesenteric fascia and periparotid fascia. Those were not in view. The edges of the woundwere freshened using the sharp scalpel and an attempt was made to fashion a rhomboidwound with apices at 12:00, 6:00, 3:00, and 9:00. The skin of the external auditory canal waspartially denuded down to the cartilage. Helical rim cartilage as well as antihelical cartilageas it approached the superior was exposed. The cartilage was trimmed back with sharpscalpel to allow for advancement of skin edges. The entire wound was undermined severalcm and a subcutaneous plane taking care to maintain a thin flap and prevent neuronaldamage. A rhomboid flap was outlined with limb extending from the anterior apex at 9:00and then angled sharply downward towards the angle of the jaw for 5 cm. The rhomboid wasthen elevated by sharp dissection again maintaining an adequate layer of fat beneath the skinbut staying above the SMAS. Rotation of the flap failed to result in adequate closure of thedefect. It was decided at this point that further advancement of the flap would benecessary. The limb extending inferiorly was further lengthened to just beyond the angle ofthe mandible. A bolus triangle was sketched onto the skin with a marking pen on both thesuperior and inferior limb of the flap. Additional undermining of the flap down into the neckwas performed and the flap was advanced with closure of the triangle and allowing thesuperior portion of the flap to reach the cephalic margin of the defect. Utilizing carefulatraumatic tissue techniques with skin hooks only, the flap was advanced and while holdingthe flap in position, several stay sutures of interrupted #4-0 chromic suture were placed ininverted buried fashion at the corners of the flap. Once this was accomplished, thesubcutaneous tissues were closed around the entire defect with additional row of interrupted#4-0 chromic suture. The edges of the skin were carefully approximated and everted and aseries of interrupted simple #5-0 nylon sutures were employed to close the skin. Careful




attention was given to preservation of the external auditory canal. Cartilage was removedto a point where canal skin could be gently advanced and sutured to the flap. Theexternal auditory canal was lightly packed with Xeroform gauze. Xeroform gauze wasplaced over all suture line and soft dressing with sponges was placed over the gauze andKling was applied as a circumferential turban wrap.

The patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Less than 25 cc.

COMPLICATIONS:None

SPECIMEN:None

DISPOSITION:To PACU





Operative Report

PRE-OPERATIVE DIAGNOSIS:Massive severe folliculitis of the posterior neck.

POSTOPERATIVE DIAGNOSIS:Same.

OPERATION:Excision of folliculitis – 20 x 9 cm tissue down to muscle with advance and flapclosure.

ANESTHESIA:Local.

DESCRIPTION OF PROCEDURE: After this gentleman was placed on hisabdomen in a totally prone position, appropriately protected, he was prepped and draped.The area to be excised was marked and able to be excised in a wedge-type excisiontaking it down to the underlying muscle fascia. Hemostasis was achieved with cautery asthe procedure progressed. All areas of infected and involved tissue and scar tissuewas removed. After the tissue was removed, hemostasis was achieved with additionalcautery and verified with irrigation. Undermining the superior portion was carriedout in order to advance a flap and the wound was able to be closed using tensionsutures of 3-0 nylon and then interrupted 4-0 nylon and a running 4-0 Prolene. Penrosedrains were brought out in each corner and sutured to place. An appropriate pressuredressing with a neck collar was applied. The patient is going to be discharged to befollowed by me as an outpatient. He has been instructed and given instructions inwriting.




Department of Pathology

TISSUES

A. SKIN – FOLLICULITIS POSTERIOR NECK

FINAL DIAGNOSISCystic folliculitis, posterior neck.





Operative Report

PREOPERATIVE DIAGNOSIS:Wide excision of basal cell carcinoma of the left forehead with advance and flap closure.

POSTOPERATIVE DIAGNOSIS:Same.

OPERATION:Excision of basal cell carcinoma.

ANESTHESIA:Local.

After this lady was prepped with Betadine, carefully marked, injected with 1% Xylocainewith adrenaline, the entire area was able to be excised as a large ellipse measuring 4cm x 2.5 cm. The wound was able to be closed primarily after the flaps wereundermined, they were able to be advanced with interrupted 4-0/5-0 nylon andProlene. She tolerated the procedure well and has been instructed. A pressure dressing isapplied and she will be followed by me as an outpatient.





Department of Pathology

TISSUES

A. SKIN – SCALP LESION.

FINAL DIAGNOSISSkin from scalp: Basal cell carcinoma, tumor extends close, but not into the narrowmargin. Deep margin is free of tumor.




Exercise 9: Please read the following Operative Report and assign the appropriate CPTcodes and modifiers.

Operative Report

PREOPERATIVE DIAGNOSIS:Squamous cell carcinoma of right ear posteriorly, recurrent.

POSTOPERATIVE DIAGNOSIS:Squamous cell carcinoma of right ear posteriorly, recurrent.

OPERATIVE PROCEDURE:Multiple frozen sections and excisions of squamous cell carcinoma of the right ear with alarge anteriorly based flap reconstruction measuring 5 x 6 cm.

DESCRIPTION OF PROCEDURE:The patient was given intravenous sedation. The area which was basically along thesulcus of the posterior surface of the ear, was marked out with a fine-tip marking pen, andthen taking skin from the posterior surface of the ear, as well as from the mastoid. Thesuture was placed at the 12 o’clock position. Dissection was carried down to the loweraspect of the ear. The frozen section margins came back clear on the edges, but therewas some tumor on the deep surface. This was adjacent to the cartilage. Therefore, thecomplete cartilage under this area was excised. This was basically from the helix, allthe way back, down to the sulcus, for about two-thirds or slightly more of the ear. Thiswas completely resected. Ink was placed on the anterior concave site and the posteriorold deep margin was completely excised with a specimen down to the site of the head. Afurther deep margin was taken in the soft tissue part posterior to the cartilaginouscomponent and a completely new deep margin was resected.

This was copiously irrigated with saline and checked for hemostasis with bipolar cautery.A large flap, 5 x 6 cm, was advanced from an anterior based position to mobilize thistissue and allow closure with interrupted deep 5 and 6-0 Monocryl in the deep layersand 4-0 running Chromic on the skin. The ear was packed with moist cotton balls andlight gauze dressing with cling applied. The patient tolerated the procedure well and leftthe operating area in good condition. The sponge, needle, and instrument counts werecorrect. It should be noted that the patient had a blood loss of less than 20 cc.





Operative Report

PREOPERATIVE DIAGNOSIS:Multiple left post auricular cysts, right upper eyelid soft tissue lesion/

POSTOPERATIVE DIAGNOSIS:Multiple left post auricular cysts, right upper eyelid soft tissue lesion/

OPERATION:Excision multiple left post auricular cysts, excision right upper eyelid lesion.

ANESTHESIA:Local general, a total of 6 cc of half-and-half mixture of .05% Lidocaine withEpinephrine and 0.5% Marcaine with Epinephrine.

ESTIMATED BLOOD LOSS:Minimal.

SPECIMENS:1. Post Auricular Cyst.2. Right Upper Lid Lesion.

DRAINS:NONE.

COMPLICATIONS:NONE.

INDICATIONS FOR PROCEDURE:The patient is a 49-year old male with a history of multiple post auricular cysts that havegone through flares and resolution. However, he has multiple areas that continually drain




and require excision to avoid further flares. The patient also has a history of mitral valveprolapse, which put him at risk every time that he does have a flare-up. The patient alsohas left upper eyelid margin lesion that is 2 mm by 3 mm in length and is continuingto grow over the last approximately year to two years. It is fleshy in nature andpedunculated. Biopsies are indicated for diagnostic purposes.

DETAILS OF PROCEDURE:The patient was brought into the operating room and placed on the table in supineposition. After the induction of general anesthesia and the Ultra-Dex prep, the areas wereanesthetized with the aforementioned anesthetic mixture. An elliptical incision was thenmade in the post auricular fossa and the lesion was excised. There were clearly at leastsix, if not seven cysts in the area in the post auricular region that were excised in total. Asmall post auricular flap was then elevated on the mastoid side and advancedforward, and the wound was then closed with a combination of 4-0 Monocrylinterrupted inverted deep dermal sutures, followed by a running 6-0 Prolene postauricular stitch, followed a bolster using 3-0 nylon, moist cotton, and Xeroform.

Attention was then turned to the right upper eyelid lesion. The area was then flushedwith BSS and an eye protector was placed. The corneal protector was placed. The eyelidwas grasped and the lesion was excised at the epidermal/derma; interface trying tomaintain as may eyelashes as possible that were growing right through this area. Thelesion was removed in three pieces. TobraDex ointment was placed.

The patient tolerated the procedure well and was allowed to transport awaken and alert tothe recovery room in stable condition. At the end of the case all instrument and spongecounts were correct. Dr. R. was present and scrubbed for the entire case.




Surgical Pathology Report

Specimen(s) ReceivedA: lesion left posterior earB: right upper eye lid lesion

Final DiagnosisA. SKIN, LEFT POSTERIOR EAR, EXCISIONAL BIOPSY:

DIAGNOSIS: RUPTURED CYST (MULTIPLE)

B. SKIN, RIGHT UPPER EYELID, BIOPSY:

DIAGNOSIS: SEBORRHEIC KERATOSIS.





Operative Report

PREOPERATIVE DIAGNOSIS:Left wrist mass.

POSTOPERATIVE DIAGNOSIS:Left wrist mass.

OPERATION:1. Excision, left wrist skin and subcutaneous tissue lesion measuring approximately

1.5 x 2 cm

2. Local transposition flap approximately 2 x 1.5 cm.

ANESTHESIA:Local

PROCEDURE/FINDINGS:Operative Findings: The patient is status post open reduction and internal fixation ofthe left distal radius fracture as well as ligamentous repair of the left scapholunateligament tear. He developed a progressively enlarging wound at the proximal aspect ofhis radial incision. The patient had significant tenderness associated with this but it didnot appear infected. Attempt at treatment with silver nitrate sticks was unsuccessful. Thelesion was full thickness to the skin; it was excised. Margins were tagged. This left adefect approximately 3 x 2 cm. This was closed with a local transposition flap.

Procedure: The patient was brought to the operating room and placed on the operatingroom table in the supine position. The left arm was prepped and draped in the usualsterile fashion after local anesthesia was given along the planned incision. The mass wasthen removed in toto. It was full thickness. Upon completion of the excision of themass, the lesion was tagged with appropriate margins being oriented with the proximalvolar aspect being tagged. This left a triangular defect of approximately 2 x 3 cm.The apex distally was sutured together. This decreased the size of the defect somewhat,however, primary closure was not achievable. As a result, a transposition flap wascreated by curving the incision proximally with a back-cut. This was then advanceddistally, and brought into the wound. Wound closure was achieved quite easily. The




wound was irrigated copiously. Then 4-0 nylon sutures were used in a simple fashion toclose the incision. A sterile dressing was applied.

The patient was brought to the recovery room in stable condition, having tolerated theprocedure well.





TISSUE REMOVED

A. Left forearm skin lesion, status post ORIF, stitch is proximal volar/ORIF-May 1, 2002.

FINAL DIAGNOSIS

Skin, left forearm, excisional biopsy: Keratoacanthoma involving the inked lateral (12 to9 to 6 o’clock) margin of excision.




Exercise 12: Please read the following Operative Report and assign the appropriate CPTcodes and modifiers.

Operative Report

PREOPERATIVE DIAGNOSIS:Ischemic skin ulcer left hand.

POSTOPERATIVE DIAGNOSIS:Ischemic skin ulcer left hand.

OPERATION:Transposition flap left hand length of flap approximately 8 cm.

ANESTHESIA:General.

OPERATIVE FINDINGS:The patient had an ulcer on the dorsal aspect of his left hand. It progressed in size. Thepatient has a dialysis A-V fistula in the proximal aspect of the left arm. He has haddifficulty healing this ulcer despite aggressive wound management in our Wound CareCenter. The wound has progressively gotten bigger. At the time of surgery transpositionflap was attempted. The dorsal skin on the hand had poor perfusion. There was evidenceof numerous thrombosed dorsal hand veins. There was evidence of some fibrotic tissuedorsal to the tendons as well. The transposition flap allowed coverage of a majority ofthe defect which measured approximately 25 mm x 20 mm; however, the ulnar mostaspect was unable to be covered successfully. Approximately 90% of the defect wascovered. The risks, benefits and alternatives of this procedure were discussed. Thepatient was told of the high likelihood of failure of a local transposition flap given thepoor perfusion of the hand but it was decided that this would be the first step at attemptedreconstruction and if this was unsuccessful perhaps more extensive reconstruction such asgroin flap maybe indicated.

PROCEDURE/FINDINGS:The patient was brought to the operating room and placed on the operating room andplaced on the operating room table in the supine position. General anesthesia wasinduced. The old dorsal wound with the above mentioned dimensions was excisedand it was triangulated. This allowed for a transposition flap, which was radially andproximally based to be rotated. The line of transposition was a curvilinear line extendingfrom the dorsal




ulnar distal aspect of the hand proximally and radially to the wrist flexioncrease. The skin and subcutaneous tissue was divided. Attempt was made to preservethe subdermal vasculature with the skin; however, there was evidence of significantfibrosis in this layer and poor perfusion to this skin flap. There was some bleedingapparent at the time of the incision. The transposition flap was then advanced and asmall back cut was made at the proximal aspect. This allowed advancement of theflap to cover the majority of the defect. Then 3-0 nylon was used to advance the flap.The wound was irrigated copiously, sterile and moist dressing was applied, a splint wasapplied and the patient was brought to the recovery room in stable condition.





Operative Report

PREOPERATIVE DIAGNOSIS:Basal cell carcinoma, right side of nose.

POSTOPERATIVE DIAGNOSIS:Basal cell carcinoma, right side of nose over the ala of the right nostril.

PROCEDURE PERFORMED:Wide excision of basal cell carcinoma, right side of nose, frozen section biopsy, andreconstruction of defect with advancement of local flaps.

ANESTHESIA:Local 1% lidocaine with epinephrine solution.

Indications:The patient is a 72-year old female who was referred to me with a history of havingnoticed a lesion over the right side of the most which was biopsed and proven to be abasal cell carcinoma. The patient was referred to me for evaluation and management ofthe same.

The past medical history includes history of hypertension and bronchitis. Medications:The patient is on hydrochlorothiazide. No known drug allergies. Physical examinationreveals a 72-year old female who is alert and oriented. General examination is normal.Examination of the face reveals a lesion over the right side of the nose between the tip ofthe ala of the right nostril and the groove between the ala and right side of the patient’snose. The lesion measures about 1.5 cm in length and about 8-9 mm in width. There wasno other lesion. The rest of the examination is normal.

Procedure: The patient was placed in the supine position. The right side of the faceand nose were prepared and draped in the usual sterile fashion. An incision was markedout encircling the lesion above the ala of the right nostril in the groove.

The area was then injected with local anesthesia and following satisfactory anesthesia,the incision was made and the lesion together with the surrounding skin was excisedfull thickness down to the cartilage. Hemostasis was attained. Next a skin flap wasmobilized from over the right cheek and the incision was extended to the nasolabial fold.The cheek flap was mobilized and advanced into the defect to close the defect




without any tension on the suture line and without pulling of the right nostril.

The advanced flap was then accurately approximated using #5-0 Monocryl interruptedinverted muscular and subcutaneous sutures.

The skin edges were then accurately approximated using #6-0 nylon interrupted verticalmattress sutures. The flap was sutured into place. Hemostasis was confirmed, and thewound was then dressed with Seri-Strips. The procedure was terminated.

The patient tolerated the procedure well and did not have any intraoperativecomplications. She was discharged home with instructions to keep the dressing dry, takeantibiotics as prescribed and come back to the office in one week’s time for removal ofstitches.





Pathologic Diagnosis:BASAL CELL RT NOSE: Infiltrating Basal Cell Carcinoma Extending to the DeepMargin. Superior and Inferior Margins Negative for Tumor.

Nature of Specimen:BASAL CELL RT NOSE.




ANSWER KEY:The answers below are based on the 2004 edition of the CPT code book.

Exercise 1

1. What was (were) the diagnostic reason(s) for the encounter/visit? Basal CellCarcinoma, left ear.

2. The basal cell carcinoma was located behind the helical dome of the left ear.a. true

3. What were the dimensions of the site from which the basal cell carcinoma wasexcised? 2 cm x 2 cm (4 sq cm)

4. What type of adjacent tissue transfer was applied to the basal cell carcinoma defectsite?

c. rotational flap

5. What was the donor site for the adjacent tissue that was transferred to the basal cellcarcinoma defect site?a. superior region of the defect site

6. What were the dimensions of the donor site for the rotation flap? 3 cm x 1.5 cm(4.5 sq cm).

7. How was the donor site for the rotation flap closed?b. advancement flap application

8. Rotation flap is also called?a. transpositional flapc. interpolation flap



9. Please list the CPT surgery codes and modifier codes for this case:

14060 Adjacent tissue transfer or rearrangement, eyelids, nose, earsand/or lips; defect 10 sq cm or less

14060-59 Adjacent tissue transfer or rearrangement, eyelids, nose, earsand/or lips; defect 10 sq cm or less – Distinct ProceduralService

Exercise 2

11441 Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids,nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm

14001 Adjacent tissue transfer or rearrangement, trunk defect sq cm to sq cm

Exercise 3

14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth,neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm



Exercise 4

14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips;defect 10 sq cm or less

11311-59 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids,nose, lips, mucous membrane; lesion diameter 0.6 cm to 1.0 cm-Distinct Procedural Service

Exercise 5


Exercise 6


Exercise 7


Exercise 8

14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth,neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less



Exercise 9

14061 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm

Exercise 10


11440-59 Excision, other benign lesion including margins (unless listed elsewhere),face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cmor less- Distinct Procedural Service

Exercise 11

14020 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10sq cm or less

Exercise 12

14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth,neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less



Exercise 13

14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/orlips; defect 10 sq cm or less

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