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Prolene. She tolerated the procedure well and has been instructed. A pressure dressing is applied and she will be followed by me as an outpatient.

Exercise 8—continued

Department of Pathology

TISSUES

A. SKIN – SCALP LESION.

FINAL DIAGNOSIS

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

All CPT Codes © 2003 American Medical Association 35 Exercise 9: Please read the following Operative Report and assign the appropriate CPT

codes 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 a large anteriorly based flap reconstruction measuring 5 x 6 cm.

DESCRIPTION OF PROCEDURE:

The patient was given intravenous sedation. The area which was basically along the sulcus of the posterior surface of the ear, was marked out with a fine-tip marking pen, and then taking skin from the posterior surface of the ear, as well as from the mastoid. The suture was placed at the 12 o’clock position. Dissection was carried down to the lower

aspect of the ear. The frozen section margins came back clear on the edges, but there

was some tumor on the deep surface. This was adjacent to the cartilage. Therefore, the

complete cartilage under this area was excised. This was basically from the helix, all

the way back, down to the sulcus, for about two-thirds or slightly more of the ear. This was completely resected. Ink was placed on the anterior concave site and the posterior old deep margin was completely excised with a specimen down to the site of the head. A

further deep margin was taken in the soft tissue part posterior to the cartilaginous

component 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 this

tissue and allow closure with interrupted deep 5 and 6-0 Monocryl in the deep layers and 4-0 running Chromic on the skin. The ear was packed with moist cotton balls and

light gauze dressing with cling applied. The patient tolerated the procedure well and left the operating area in good condition. The sponge, needle, and instrument counts were correct. It should be noted that the patient had a blood loss of less than 20 cc.

Exercise 10: Please read the following Operative and/or Pathology Report and assign the

appropriate CPT codes and modifiers.

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 with Epinephrine and 0.5% Marcaine with Epinephrine.

ESTIMATED BLOOD LOSS:

Minimal.

SPECIMENS:

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

DRAINS:

All CPT Codes © 2003 American Medical Association 37 Exercise 10—continued

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

pedunculated. Biopsies are indicated for diagnostic purposes.

DETAILS OF PROCEDURE:

The patient was brought into the operating room and placed on the table in supine

position. After the induction of general anesthesia and the Ultra-Dex prep, the areas were anesthetized with the aforementioned anesthetic mixture. An elliptical incision was then made in the post auricular fossa and the lesion was excised. There were clearly at least six, if not seven cysts in the area in the post auricular region that were excised in total. A

small post auricular flap was then elevated on the mastoid side and advanced forward, and the wound was then closed with a combination of 4-0 Monocryl

interrupted inverted deep dermal sutures, followed by a running 6-0 Prolene post auricular 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 flushed with BSS and an eye protector was placed. The corneal protector was placed. The eyelid was grasped and the lesion was excised at the epidermal/derma; interface trying to maintain as may eyelashes as possible that were growing right through this area. The

lesion was removed in three pieces. TobraDex ointment was placed.

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

Exercise 10—continued