![]() This mass was at the areolar border at approximately the outer central to lower outer quadrant.(Specific location of the breast mass.) I made a circumareolar incision on the outer aspect of the areola. I anesthetized the area in question with the mixture noted above. The right breast(The procedure was performed on the right breast.) was prepped and draped in the usual fashion. Both arms were placed comfortably out at approximately 85 degrees. She was then brought back to the operating room where she was placed on the operating room table in supine position. FINDINGS AT THE TIME OF OPERATION: This appeared to be a fibroadenoma.("Appeared to be" would not be considered a definitive diagnosis.) OPERATIVE PROCEDURE: The patient was first identified in the holding area and the surgical site was reconfirmed and marked. ![]() This has grown somewhat in size and we decided it should be excised. INDICATIONS: The patient is a 23 year-old female who recently noted a right breast mass (lower outer quadrant). POSTOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant.(Postoperative diagnosis is used for coding.) PROCEDURE: Right breast lumpectomy.(Procedure to be performed.) ANESTHESIA: A 1% lidocaine with epinephrine mixed 1:1 with 0.5% Marcaine along with IV sedation. What CPT® and ICD-10-CM codes are reported?ĬASE 3 PREOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant. Hill from Plastics with a Burow's graft.(A Burow's graft is not reported because it was performed by a different provider.) CONDITION AT TERMINATION OF THERAPY: Carcinoma removed. Following surgery, the defect measured 10 x 13 mm to the subcutaneous tissue.(Size and depth of the defect.) Closure will be done by the Dr. The surgeon examined the tissue and no microscopic tumor was found persisting in the tumor margins on the tissue blocks. ![]() The tissue was divided into two tissue blocks (The tissue is divided into two tissue blocks.) which were mapped, color coded at their margins, and sent to the technician for frozen sectioning. Additional soft tissue markings were created to keep the specimen oriented with the excision site.(Noting the tumor has been removed, which supports stage 1.) Hemostasis was obtained by electrocautery. ![]() The area of the tumor and margins were marked for excision. The wound was defined and infiltrated with 1% lidocaine with epinephrine 1:100,000 (Local anesthesia was used). The patient was placed supine on the operating table. STAGE I: (Mohs surgery is performed in stages, this report indicates only one stage) The site of the skin cancer was identified concurrently by both the patient and doctor and marked with a surgical pen the margins of the excision were delineated with the marking pen. Informed consent was obtained and the patient underwent fresh tissue Mohs surgery as follows. Mohs surgical procedure was explained including other therapeutic options, and the inherent risks of bleeding, scar formation, reaction to local anesthesia, cosmetic deformity, recurrence, infection, and nerve damage. CASE 1 PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (postoperative and preoperative diagnosis) POSTOPERATIVE DIAGNOSIS: Same OPERATION Mohs micrographic surgery (Mohs surgery is performed) Indications: The patient has a biopsy proven basal cell carcinoma on the nasal tip (Location) measuring 8 x 7 mm.(Size) Due to its location, Mohs surgery is indicated.
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