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Certificate of AttendanceAdvanced Clinic: Skin Graft CPT Coding

June 10, 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 Skin Grafts

All CPT Codes 2002 American Medical Association* Lolita M. Jones Consulting Services 1

Advanced Clinic:

Skin Graft

Presenter:

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.com

E-mail: [email protected]

Distributed by HCPro, Inc.

Advanced Clinic: Skin Graft

Presenter:Lolita M. Jones, RHIA, CCS

Lolita M. Jones Consulting Services1921 Taylor Avenue

Fort Washington, MD 20744(V) 301-292-8027

(FAX) 301-292-8244Coding Training: www.hcprofessor.com


Advanced Clinic Flaps and Grafts

All CPT Codes © 2003 American Medical Association

2

Table of Contents

Disclaimer 3

About Lolita M. Jones Consulting Services 4

I. Skin Grafts 5

Exercises 11

Answer Key 50



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DisclaimerAdvanced Clinic: Skin Grafts is designed to provide accurate and authoritative information in regard to thesubject covered. Every reasonable effort has been made to ensure the accuracy of the information withinthese pages. However, the ultimate responsibility lies with the user.

Lolita M. Jones Consulting Services and staff make no representation, guarantee or warranty, express orimplied, that this compilation is error-free or that the use of this publication will prevent differences ofopinion or disputes with Medicare or other third-party payers, and will bear no responsibility or liability forthe results or consequences of its use.

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

Please contact Lolita M. Jones, RHIA, CCS at:(V) 301-292-8027(Fax) 301-292-8244Coding Training: www.EZMedEd.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 useof the original purchaser. This consent does not extend to other kinds of copying, such as for generaldistribution, for advertising or promotional purposes, for creating new collective works, or for resale.

• GRAFT



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About Lolita M. Jones Consulting ServicesCoding Training: www.hcprofessor

(V) 301-292-8027(FAX) 301-292-8244


BIOGRAPHY:

Lolita M. Jones, RHIA, CCS, is an independent consultant specializing in hospitaloutpatient and ambulatory surgery center coding, billing, reimbursement, and operations.Ms. Jones recently launched her web-based coding program at www.EZMedEd.com.She has over 15 years of experience in publishing, training, and auditing for the hospitaloutpatient and freestanding ambulatory surgery center (ASC) markets. Ms. Jones hasearned both the Registered Health Information Administrator and Certified CodingSpecialist credentials from the American Health Information Management Association(AHIMA) in Chicago, IL. Ms. Jones resides in Fort Washington, Maryland, and she hasdeveloped six (6) specialty manuals for freestanding ambulatory surgery centers (ASCs)as well as comprehensive manuals for hospital outpatient ambulatory paymentclassification (APC) training programs.



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I. Skin Graftsa. Code 15000 specifically applies to excision of open wounds, burn eschar or scar.Code 15000 was revised (in CPT 1999) to reflect a stand-alone procedure to be used inthe circumstances when a skin graft is not recommended (e.g., partial thickness burns) orwhen grafting is delayed for a subsequent session. Previously 15000 was an “add-on”code which could only be used in conjunction with a skin graft code.

Use code 15000 for initial wound preparation for application of a skin graft.

Code 15000 represents excisions up to and including the first 100 sq cm. (Source: CPTAssistant newsletter, January 1999, page 10).

b. Code 15000 should also be used as a stand-alone code when alloplastic dressingsare applied. Alloplastic dressings consist of synthetic materials (e.g., plastic, metal), andare applied immediately following the excisional procedure to enable the wound togenerate new skin elements without autografting. Some common manufacturer’s namesfor alloplastic dressings are BGC®, Biobrane®, Exudry®.

c. Code 15001 is a new add-on code for surgical preparation of a site for eachadditional 100 sq. cm. Use code 15001 in conjunction with code 15000, code 15001 is anadd-on code that cannot be reported without code 15000.

Code 15001 includes excision of wounds that involve additional centimeters beyond theinitial 100 cm. up to and including the additional 100 sq cm. (Source: CPT Assistantnewsletter, May 1999, page 10).

d. For appropriate skin grafts, see 15050–15261; list the free graft separately by itsprocedure number when the graft, immediate or delayed, is applied.

e. The skin graft codes include language that indicates use of the codes according tothe total surface area of the repair provided for those body areas addressed by thatspecific code. If multiple sites that area grafted, are all identified by the same graft code,the application of graft code should be used once to identify the complete procedureprovided. (Source: CPT Assistant newsletter, November 2000, page 10).

f. Skin grafts are identified by size and location of the recipient area and the type of graft:free, pedicle flap or other. Do not assign a code for the repair of the donor site unless skingrafting or local flaps are required to close the donor site.

g. For codes 15000, 15001, 15100, 15101, 15120, 15121 when determining theinvolvement of body size the measurement of 100 sq. cm is applicable to adults andchildren age 10 and over, percentages apply to infants and children under the age of 10.



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h. Skin graft codes include language that indicates the use of the codes according tothe total surface area of the repair provided for those body areas addressed by thatspecific code. Therefore, if grafts are applied in different anatomic locations describedwithin a single code description, the correct code(s) should be assigned according to theappropriate size and location of the defect repaired.

Example: A physician performs a full thickness skin grafting procedure of 3 sq cm for afinger, cheeks, and chin. Since fingers, cheek, and chin are all identified by the same fullthickness graft code, covered with graft totaled 9 sq cm. code 15240 should be used onceto identify the complete procedure provided. (Source: November 2000 CPT Assistantnewsletter).

i. Pinch Graft: Code 15050 is used to identify a small area requiring a relocatedportion of skin (a “pinch” of skin). This code would be used only once regardless of thenumber of pinch grafts performed to cover a defect 2cm or less. (Source: CPT Assistantnewsletter, September 1997, page 2.)

j. Derma-fascia-fat Graft: Code 15770 is reported once per graft site. (Source: CPTAssistant newsletter, September 1997, page 12.)

k. Punch Graft: CPT codes 15775 (1 to 15 punch grafts) and 15776 (more than 15punch grafts) are used for the transplant of hairline to correct hair loss or for revision ofscarring such as “ice-pick” acne scars. The graft is performed by removing smallamounts of circularly excised portion of scalp or hair-containing tissue strategicallyplaced in areas of the hairline devoid of hair. The two codes would not be reportedtogether - they are mutually exclusive. (Source: CPT Assistant newsletter, September1997, page 12.)

l. Undermining is the process by which the dermis is separated from the epidermis, ortwo layers of dermis are separated, for skin graft application. This procedure is part of theoverall skin grafting procedure and should not be coded separately.



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m. Skin Substitute/Neodermis:

Code 15342 (Application of bilaminate skin substitute/neodermis: 25 sq cm)should be reported for the total body surface area involved and should not tobe reported per wound site. (Source: April 2001 CPT Assistant newsletter,AMA).

Codes 15342, 15343 include application of skin substitute / neodermis.Integra®, Alloderm®, Dermagraft® are brands of bilaminate skinsubstitute/neodermis. Procedures are coded by recipient site.

To code and bill the skin substitute/neodermis, see the following codes if appropriateand/or accepted by the third-party payer:

J7342 Dermal tissue, of human origin, with or without other bioengineered or processed elements, with metabolically active elements, per square centimeter

Q0183 Dermal tissue, of human origin, with and without other bioengineered orprocessed elements, but without metabolically active elements, per squarecentimeter



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n. Tissue-Cultured Skin Grafts: Use 15100-15261 for autogenous skin grafts. Forautogenous tissue – cultured skin grafts, use 15100-15121. These codes includeharvesting of keratinocytes and their subsequent application. Procedures are coded byrecipient site.

For staged application procedure(s), use Modifier –58 (Staged or RelatedProcedure or Service by the Same Physician During the Postoperative Period).For hospital outpatient reporting to Medicare, ensure that modifier –58 isreported to indicate the performance of a procedure or service during the samecalendar day postoperative period.

Codes 15350 (Application of allograft skin; 100 sq cm or less) and 15400(Application of xenograft skin; 100 sq cm or less) should be reported for thetotal body surface area involved and not per wound site. (Source: April 2001CPT Assistant newsletter, AMA).

See also Exhibit 1: Graft Definitions.



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Exhibit 1: Graft Definitions

Alloplastic dressing or graft—Graft of an inert metal or plastic material. Anyinert foreign body used for implantation into tissues.

Allogenic (homograft)—Homograft is a graft from the same species (human).

Xenograft (heterograft)—Xenograft is a graft from an animal of a species of oneorder to that of another order (e.g., “porcine graft”). A porcine graft is a biologicdressing that can be utilized following excision of full thickness grafts as atemporary dressing or following surgical preparation of partial thickness grafts as abiologic dressing.

Tissue cultured skin grafts—Include cultured keratinocytes which are harvestedfrom auto and/or allogenic skin, or which utilize non-cellular material whichmimics the physical properties of the epidermis (e.g., combines both non-cellularmaterial and cultured skin cells (composite grafts). These types of skin substituteshave evolved over the past fifteen years, and at this time are limited, but offer somepromise in skin wound coverage. Tissue-cultured skin grafts often are performed assecond stage procedures.

Source: CPT 1999 Coding Symposium, Nov. 11-13, 1998, Chicago,IL—Presenter: Robert W. Gillespie, M.D., medical director for Nebraska HealthSystems Burn Center at Clarkson Hospital in Omaha, and clinical professor ofsurgery for the University of Nebraska College of Medicine in Omaha.



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11

Exercise 1

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:Squamous cell carcinoma, right medial malleolus.

POST OPERATIVE DIAGNOSIS:Ankle basal cell carcinoma, right medial malleolus.

OPERATION PERFORMED:

Excision of basal cell carcinoma, right medial ankle with split thickness skin graftcoverage.

ANESTHESIA:General, LMA.

ESTIMATED BLOOD LOSS:Minimal.

ANTIBIOTICS:Ancef 1 gm IV.

SPECIMENS:1. Excised tissue for frozen section.2. Additional margin for frozen section.

INDICATIONS:

The patient is a 69-year old, white female who was seen at the wound center by Dr.Minch. She had a biopsy done of a chronic venous stasis ulcer which has been presentfor many, many years. This showed what appeared to be squamous cell carcinoma. Sheis now brought for definitive excision.

PROCEDURE:

The patient was positioned supine. She was then anesthetized and LMA placed. Theright thigh and right foot and ankle were prepped separately and draped. An ellipse oftissue was taken encompassing all of the open areas of the right medial anklemeasuring 6.5 x 2.5 cm. This was sent for frozen section with the superior marginlabeled. There was not an adequate margin at three o’clock and therefore second piece oftissue was taken and sent, this time having clear margins. This left an open area of 7.5 x2.5cm A split thickness skin graft was taken with the Padgett dermatome from the



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Exercise 1 – cont’d

right anterior thigh. This was meshed 1.5:1 and then positioned and affixed in place tocover the wound using interrupted 4-0 chromic sutures circumferentially and in thewound itself as needed. Adaptec, mineral oil soaked cotton balls were placed over thewound over which Adaptic, fluffs, and Kerlix was applied. This was taped securely inplace. The donor site was dressed with Xeroform gauze and 4x4s. This completedthe procedure, and the patient was extubated and transported to the PACU in stablecondition.

ICD-9-CM Diagnosis Code(s): _____________________________________________ICD-9-CM Procedure Code(s): ____________________________________________CPT Procedure/Modifier Code(s):__________________________________________



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Exercise 2

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:Previously excised squamous carcinoma of the back, 3.0 x 3.0 cm.

POSTOPERATIVE DIAGNOSIS:Previously excised squamous carcinoma of the back, 3.0 x 3.0 cm.

OPERATION PERFORMED:Split-thickness skin graft from the right thigh to the left mid back.

ANESTHESIA:

PROCEDURE:

The patient was supine. The right thigh was prepped with Betadine Solution and steriledrapes were applied. A field block was inserted using 1% Xylocaine. Mineral oil wascoated over the graft donor site and the air-driven dermatome was used to take a 4.0 x4.0 cm piece of skin that was 0.0061 of an inch in thickness. Temporary steriledressings were applied. Skin was placed in saline for storage.

The patient was turned prone. The recipient site was prepped with Betadine Solutionand sterilely draped. Skin was brought up and affixed to the wound with stainless steelstaples. The graft was placed on very flat and there was no drainage at the time ofthe grafting. For granulating, #3-0 Vicryl sutures were placed at the edges. A piece ofXeroform was placed over the graft. A piece of damp cotton ball was placed over thatand held on by tying together the ends of the quadrangulating Vicryl sutures. Fluffs andsterile dressings with Benzoin and Elastoplast were applied.

The patient was turned back into the supine position. Temporary dressings were removedfrom the thigh. There was good homeostasis. A small piece of scarlet red dressingwas place directly over the donor site. Sterile dressings were placed over that.

The patient tolerated the procedure well. We gave him a prescription for Cephalexin500mg qid x7 days. He already has analgesics at home. He will return to the office forfollow-up in six days.



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Exercise 2—continued




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Exercise 3

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:Third degree burn, left lateral arm (13 X 5 cm)

POSTOPERATIVE DIAGNOSIS:Third degree burn, left lateral arm (13 x 5 cm)

OPERATION PERFORMED:

1. Tangenital excision of burn wounds left lateral arm.2. Split thickness skin graft, left lateral arm.

ANESTHESIA:Local.

ESTIMATED BLOOD LOSS:Trace.

COMPLICATIONS:None.

OPERATIVE INDICATIONS:

The patient is a 37-year old female with a past medical history significant for Crohn’sdisease, emphysema and chronic oxygen use who presents after burning her left upperextremity while smoking in bed. The patient sustained a burn wound measuringapproximately 13 x 5 cm on the lateral aspect of her arm. After discussing the risksand benefits of surgical excision including but not limited to bleeding, infection, poorwound healing, scar formation, she elects to proceed.

PROCEDURE:After obtaining informed consent, the patient was taken to the operating room and placedon the table in a supine position. The area of the arm and left lateral thigh were preppedand draped in the usual sterile fashion.

Using a Goulan knife with a guard of 10:1000th of an inch, the burn wound wastangentially excised. This was done until all obviously nonviable tissue had beenremoved. Next, a Zimmer dermatome set a 12:1000th of an inch was used to harvest askin graft measuring approximately 15 x 5cm. The donor site was then coveredwith a sterile dressing consisting of Xeroform guaze and an ABD pad. The skin graftwas then cut to an appropriate configuration and stapled to the edges of the defect.Sutures of 3-0 silk were then placed circumferentially around the site of skin graft which



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were then tied over a bolster dressing consisting of bacitracun ointment, Adaptic andsterile cotton . Additional dressing of fluffs, a Kerlix roll and an Ace bandage wereplaced over the bolster dressing. The patient tolerated the procedure well, was extubated,and transported to the recovery room in stable condition. Total area of skin grating was13 x 5cm.





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Exercise 4

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:Chronic left leg wound, 1.4 centimeters circular.

POSTOPERATIVE DIAGNOSIS

OPERATION PERFORMEDExcision of left leg wound and full-thickness skin graft coverage 2.5 centimeters.

ANESTHESIALocal (1% lidocaine with epinephrine).

ESTIMATED BLOOD LOSSMinimal.

INDICATIONS

Sharon was 43 years old and presented to the Medical Center Wound Care Center in Mayof this year. She had undergone cryotherapy of a left leg lesion on April 24, 2002.After that, the wound had healing difficulties, including infection. We treated herwith serial debridements and dressing changes to bring the wound to where it is today.The wound was taking a very long time to heal and I discussed with her that in order toexercise the healing process so that she could get on with her life, I would recommend asplit-thickness skin graft. We discussed the risks, including, but not limited to, infection,bleeding, abnormal scarring, graft loss, possible need for revisional surgery, and scarringin both donor and the recipient sites. The patient consented.

FINDINGSThe patient had a wound 1.4cm, circular, on the left mid-leg medially with granulationtissue on the base. There was evidence of infection.

PROCEDUREThe patient was brought to the operating room and placed comfortably in the supineposition on the OR table. The left leg and left lateral thigh were prepped and drapedsterilely as she was interfaced with the appropriate monitors. The donor site and therecipient sites were infiltrated with local anesthetic, 1% lidocaine with epinephrine times20cc. The wound was then excised tangentially using a # 10 scalpel. There waspunctuate bleeding at the base of the wound throughout. The wound was dressed withsaline – dampened gauze. A small full-thickness skin graft, 12/1000 of an inch thick,was harvested from the lateral proximal left thigh. The skin graft was placed underthe base of the wound dermis side down and stapled in place peripherally. The skinsecuring Bacitracin-slathered Xeroform and a mineral oil-dampened guaze dressing inplace. The wound was then dressed with bulky 4x4 guaze, Kerlix, and an Ace wrap.



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The donor site was dressed with Xeroform and gauze. The patient tolerated theprocedure well. Sponge, needle, and instrument counts were correct at the end of theprocedure. There were no complications.

The patient was transported to the recovery room. The patient was in good conditionpost-procedure.





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Exercise 5

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS1. Chronic open wound, left dorsal foot2. Chronic open wound, left medial foot

POSTOPERATIVE DIAGNOSES1. Chronic open wound, left dorsal foot.2. Chronic open wound, left medial foot

OPERATION1. Debridement of foot wounds2. Closure of foot wounds using Appligraf.

ANESTHESIALocal.

ESTIMATED BLOOD LOSSTrace.

COMPLICATIONSNone.

INDICATIONSThe patient is a 63-year-old non-insulin-dependent diabetic male who has chronicwounds of the left foot. This is believed to be secondary to a spider bite. The patienthas undergone multiple debridements, as well as IV antibiotic therapy for infection. Thewounds are clean, and the infection seems to be clearing. There are exposed tendonson the dorsum of the foot and therefore closure is warranted.

PROCEDURE/FINDINGSAfter obtaining informed consent, the patient was taken to the operating room and placedon the table in the supine position. Using 1% lidocaine with 1,100,000 epinephrine, theareas of the wound on the dorsal foot, as well as the medial foot were infiltrated. Afterwaiting an appropriate amount of time for the anesthetic and hemostatic effects to takeplace, the foot was prepped and draped in the usual sterile fashion. Sharpdebridement was used to remove nonviable skin and subcutaneous tissue. Thewound on the dorsum of the foot was inspected and measured approximately 7 to 8 cmin greatest dimension. The wound on the medial foot measured approximately 3cm ingreatest dimensions. After adequately debriding the wounds, Appligraf was meshed1-1/2 to 1 and placed in the wound adequately covering underlying structures. Thiswas affixed to the periphery of the wounds using staples. In total approximately 40 to45 square cm of Appligraf was used.



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Next, the dressing was applied consisting of antibiotic ointment. Adaptic, Fluffs, Kerlixroll, followed by soft roll, Ace and Copan. The patient tolerated the procedure well andwas discharged in stable condition.




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Exercise 6

OPERATIVE REPORT

PREOPERATIVE DIAGNOSISBurn, right upper extremity, 315 cm2

POSTOPERATIVE DIAGNOSISBurn, right upper extremity, 315 cm2.

OPERATION1. Excision of burn, right upper extremity.2. Split-thickness skin graft coverage of burn defect, right upper extremity. 315

cm2.

ANESTHESIAGeneral.

ESTIMATED BLOOD LOSS200cc.

INDICATIONS FOR PROCEDUREThe patient sustained a burn on July 4, 2002, to his right upper extremity. I had beenmanaging him on an outpatient basis when it became infected. I admitted him and treatedhim for the infection. With that resolved, we scheduled surgery for debridement of his 3to 4% total body surface area burn of the right upper extremity. I discussed with thepatient that the burn was in some places deep partial –thickness and in others full-thickness (second and third-degree, respectively). I discussed with him that some of theperipheral areas had healed, and they did not need to be skin grafted, but that everythingelse would not heal in a timely fashion, would give him dramatic hypertrophic scarring,and would compromise function of his right upper extremity. We discussed theprocedure and the potential complications, including but not limited to infection, graftloss, bleeding, abnormal scarring, possible need for additional surgery, and pain. With anapparent understanding, the patient signed the consent.

FINDINGSThe patient had a right upper extremity burn extending essentially from just beyond hiselbow volarly, ulnarly, and posteriorly down to the wrist. It extended up onto the handdorsally in several areas. Peripherally and up on the palm of the hand some of the burnhad already epithelialized. The remainder of this burn was gray/yellow and fullthickness. Much of it was deep partial-thickness with some buds of healthy viabletissue. The previous infection had resolved.

PROCEDUREThe patient was brought to the operating room and placed comfortably in the supineposition on the operating room table. He was placed on the appropriate monitors and



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placed under the effects of general anesthesia by the anesthesia staff. The right upperextremity and right thigh were prepped and draped sterilely.

Using a Goulian knife the nonviable skin was debrided sharply down to a bed ofhealthy, viable-appearing, and bleeding tissue throughout the entire burned area.At this point a series of epinephrine-soaked sponges were placed onto the burn, and thiswas wrapped with Kerlix.

A split -thickness skin graft was harvested from the right lateral thigh using aPadgett dermatome, and the skin graft was 0.012-inch thick. The skin graft was thenmeshed in 1 to 1.5 fashion.

The burn wrap was taken off, and hemostasis was made more complete withelectrocautery. The burn defect was pulse lavaged with a liter of sterile normal saline.

The skin graft was then placed, derma side down, onto the burn defect and stapled inplace. It was trimmed to fit along the way. Two strips of graft were taken from the rightlateral thigh. The wound at this point was hemostatic.

The wound was rinsed with sterile saline and dressed with Bacitracin-slathered Xeroformgauze, 4x4 gauze, a heavy drainage bandage, and kerlix, and an ulnar gutter splint wasplaced, extending from the fingertips up to the mid-arm. This was secured in place withan Ace wrap. The donor site was dressed with Xeroform and gauze, as well as an Acewrap.

The patient tolerated the procedure well, Sponge, needle and instrument counts werecorrect at the end of the procedure. There were no complications. The patient wasextubated and transported to the recovery room in good condition.



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Exercise 7

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:Extensive full thickness skin loss, left axilla status post dehiscent surgical wound.

POSTOPERATIVE DIAGNOSIS:Extensive full thickness skin loss, left axilla status post dehiscent surgical wound.

OPERATION PERFORMED:Debridement and split thickness skin grafting, soft tissue defect, left axilla.

ANESTHESIA:General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:Minimal.

ANTIBIOTICS:Cefotan 2 grams IV.

SPECIMENS:None.

SUMMARY OF PROCEDURE INDICATION:

The patient is a 36 year old white male who has a history of recurrent hidradentitissuppurativa of the axillae. He most recently underwent excision of affected skin in theleft axilla on 02/25/02. This was done on an outpatient basis. In the follow-up, he wasnoted to have an infection, which progressed, culminating in extensive wounddehiscence of the left axilla. Subsequently , he was treated as an inpatient with IVantibiotics and local wound care and was later transferred to an extended care facilitywhere he was continued on IV Cephazolin. Because the area of skin loss is greaterthan 15 x 15cm, he is now brought for skin grafting for coverage.

PROCEDURE:The patient is brought to the Operating Room and positioned supine. He wasanesthetized and intubated. A roll was placed behind his left shoulder and the arm waselevated on a blanket. The left anterior leg and thigh were shaved and preppedseparately from the wound, which involves the entire left axilla and superior lateralchest wall.



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The wound was debrided using the Weck knife and a #10 blade and was alsocuretted. There was one small sinus opening superiorly and this was probed, but notwidely opened as it extended into the deep axilla.

Two split thickness grafts were taken from the anterior and the anterolateral leftthigh. These were meshed 1.5:1. The donor site was covered with Xeroform gauze,4x4’s, and ABDs. These were later taped in place.

Now, the arm was extended and the graft was applied to completely cover the area.This was done with a total of four pieces. These were secured circumferentially withstaples and seams were approximated and tacked down using #4-0 chromic sutures.Excess graft was trimmed.

The site was dressed with multiple layers of Adaptic; over which mineral oil soakedcotton battering was applied. Additional layers of Adaptic were placed prior to puttingmore dry cotton batting, Fluffs and ABDs. These were taped into place and the patientwas placed into a sling. He was noted to have a left antecubital PICC line in place.

This completed the procedure and the patient was extubated and transported to the PACUhaving tolerated the event well. He will be kept on IV antibiotics for an additional eightdays, until the graft dressings are taken down.



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Exercise 8

OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:Third degree burn, left calf.

POSTOPERATIVE DIAGNOSISThird degree burn, left calf.

POSTOPERATIVE DIAGNOSISThird degree burn, left calf.

OPERATIONExcisional preparation of recipient site and split-thickness skin grafting less than 100square centimeters, left calf.

ANESTHESIAGeneral endotracheal anesthesia.

ESTIMATED BLOOD LOSSMinimal.

INDICATIONS FOR SURGERYThis is an 11-year-old white male who burnt his medial left calf on a dirt bike mufflerseveral weeks ago. The initial depth of the wound was indeterminate. The patient nowreturns back for an office visit with the eschar having sloughed and an obvious full-thickness burn. In light of this, discussions with the patient and his parents regardinglong-term conservative wound care versus excision and split – thickness skin graftingwith a presumed more immediate closed wound were reviewed. The patient and hisparents selected the later option of skin grafting. The proposed surgical procedures, risks,alternatives, expected results, perioperative routine and resultant scar as well as thepossibility for partial or total graft loss were reviewed with and accepted by the patientand his parents.

PROCEDURE/FINDINGSThe patient underwent general endotracheal anesthesia by Dr. Carnen. The patient’s leftanterolateral thigh and left calf were prepped and draped in the usual sterile manner.Quarter-percent Marcaine with 1:200,000 epinephrine was used to locally infiltratearound the respective areas. A split-thickness skin graft was then harvested with thePadgett electric dermatome measuring approximately 0.015 of an inch. This was takenfrom the left anterolateral thigh. The donor site was covered with Xeroform gauze,Adaptic, and sterile dressings at the completion of the procedure.



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The recipient site was the sharply debrided excising the entire burn wound downinto the superficial subcutaneous tissues. Bleeding was controlled usingelectrocautery. The skin graft was then mashed on the back table 1:1.5 and applied overthe recipient site, secured with a running 4-0 chromic suture. Xeroform gauze, Adaptic,cotton batting impregnated in mineral oil and saline, Sof-Roi, a posterior splint and Acewraps were then used to secure the dressing and immobilize the left lower leg.

The patient was then extubated and brought to the recovery room in stable condition.

All counts were correct.





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Exercise 9. Please read the following clinical data and assign the appropriateCPT code(s)-modifiers:______________________________________________.

OPERATIVE REPORT

OPERATION: Excision, now with margins, of squamous cell carcinoma in situ, fullthickness skin, with split thickness skin graft from the volar ulnar forearm.

ANESTHESIA: Axillary block.

PREOPERATIVE DIAGNOSIS: Squamous cell carcinoma in situ, dorsum of left fifthfinger, approximately 3 x 2 cm.

POSTOPERATIVE DIAGNOSIS: Squamous cell carcinoma in situ, dorsum of leftfifth finger, approximately 3 x 2 cm.

OPERATIVE INDICATIONS: The patient is a 70-year-old female who has had alesion on the dorsum of her fifth finger, which has been growing, and was biopsiedby her dermatologist, who showed Bowen’s disease. Therefore, she is planned for anexcision.

OPERATIVE FINDINGS: Frozen section margins were negative.

OPERATIVE PROCEDURE: The patient was brought to the operating room, axillaryblock was placed. The arm was prepared and draped in sterile fashion. The fullthickness of the dorsal skin of the fifth finger was excised with approximately 5 mmmargins around the entire lesion. This was sent for frozen section. Frozen sectionhad negative margins, with a small area of persistent dysplasia, which was re-excised. Hemostasis was obtained, and attention was turned to the graft. From themedial aspect of the antecubital fossa, a 4 x 2.5 x 0.15-inch thick split thickness skingraft was obtained with the dermatome. This was then placed easily over the excisionbed, and sewn to the finger, with #4-0 Dermalon. There was excellent fit of the graft.Wet Telfa and cotton were then placed as a compression dressing and wrapped. Thefinger was splinted, sterile dressing was placed. The patient was returned to the postanesthesia care unit in stable condition.

OPERATIVE FLUIDS: 250 crystalloid.

ESTIMATED BLOOD LOSS: None.

DRAINS: None.



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Exercise 9 - continued

Pathology Report

FINAL DIAGNOSIS:1. LEFT DORSAL FIFTH FINGER LESION, EXCISION (A) - SQUAMOUS CELL CARCINOMA IN-SITU.

- SHAVED MARGINS OF EXCISION FREE OF CARCINOMA.

Comment: The squamous cell carcinoma in situ is bowenoid type. There is focal, mild squamous dysplasia at the shaved margin involving area designated as 6 to 9 o’clock (A-4).

2. LEFT FIFTH FINGER LESION, EXCISION (B) - SEGMENTS OF SKIN WITH FOCAL HEMORRHAGE.

- NO EVIDENCE OF MALIGNANCY.

SPECIMEN(S) SUBMITTED: Part A: LEFT DORSAL FIFTH FINGER Part B: LEFT FIFTH FINGER LESION

CLINICAL DATA: BOWEN’S DISEASE, IN SITU SQUAMOUS CELL CARCINOMA

GROSS DESCRIPTION:A. The specimen is received fresh in a single container and is labeled withthe patient’s name and appropriate patient information and is unmarked. Thespecimen consists of an ellipse of skin measuring 2.5 x 2 cm. No gross identifiablelesion is identified. There is black suture placed visibly on the proximal end and awhite suture placed visibly on the distal end. The proximal end is approximatelydesignated at the 12 o’clock position and the distal end is designated at 6 o’clock.The margins from 12 to 6 are inked with black ink at this point and margins from 6to 12 are inked with red ink at this point. The lateral margins of resection are sub-mitted for a frozen section as follows: frozen section 1, from 12 to 2 o’clockposition; frozen section 2, from 2 to 4 o’clock position; frozen section 3, from 4 to6 o’clock position; frozen section 4, from 6 to 9 o’clock; frozen section 5, from 9 to12 o’clock. The deep margin is inked with yellow ink at this point, and the specimenis serially sectioned and the tissue is entirely submitted in cassettes A6-A10.

B. Received fresh are two strips of grossly appearing skin aggregate to 1.5 x 0.1x 0.1 cm. The specimen is totally submitted in formalin in one cassette.



31


INTRAOPERATIVE CONSULTATION:A. LEFT DORSAL FIFTH FINGER LESION SHAVED MARGINS, 9 TO 6 O’CLOCK SHAVED MARGINS (A-1, A-2, A-3, A-5) - NO EVIDENCE OF MALIGNANCY.

- 6 TO 9 O’CLOCK (A-4) - MILD DYSPLASIA, MORE SEVERE PROCESS CANNOT BE RULED OUT



32


OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: BASAL CELL CARCINOMA MEDIAL ASPECTOF THE RIGHT LOWER LEG AT THE ANKLE.

POSTOPERATIVE DIAGNOSIS: BASAL CELL CARCINOMA MEDIAL ASPECTOF THE RIGHT LOWER LEG AT THE ANKLE.

OPERATION: WIDE LOCAL EXCISION AND APPLICATION OF SPLITTHICKNESS SKIN GRAFT.

ANESTHESIA: INTRAVENOUS SEDATION WITH LOCAL INFILTRATION OFA SOLUTION OF 1% XYLOCAINE WITH EPINEPHRINE AND 0.5% MARCAINE.

SPECIMENS: TO PATHOLOGY - PORTIONS OF TISSUE FROM THE LOWERLEG.

ESTIMATED BLOOD LOSS: LESS THAN 15 CC.

FLUIDS: RINGERS LACTATE.

INDICATIONS: This is an 81-year-old female who had a biopsy proven lesion abovethe ankle near the aspect of the leg on the right side.

PROCEDURE: Because of the above she was taken to the operating area and in thesupine position this area was marked out and then a 5 mm. Border marked around itsperiphery. An area over the anterior lateral portion of the right upper leg was marked outas the donor site for a skin graft. Both of these areas were infiltrated with a localanesthetic, prepped with Betadine solution and sterilely draped and time allowed for thehemostatic effect of the epinephrine to take hold.

The skin incision around the lesion was made and it was removed withelectrocautery and sent to pathology. Meticulous hemostasis was achieved. A 15,000thin split thickness skin graft was then taken off the upper thigh. Topical Thrombinwas applied to this area and skin graft appropriately trimmed and placed into thedefect, sutured in with multiple interrupted #4-0 silk sutures left long for tie overs. Arunning #5-0 chromic around the periphery, it was pie crusted and then severalinterrupted chromics were placed at the base. Xeroform gauze, soggy wet cotton ballsand a tie over bolus dressing was fashioned on the lower leg. The upper wound areawas sterile cleansed and dried on the thigh. Mastisol was placed and allowed to dry



33


and then a Tegaderm dressing placed over this and then a combine taped over this.

A gauze bandage was wrapped around the tie over bolus. Kling was placed over this,then Webril from the toes to the upper portion of the midcalf was placed. A dorsalplaster splint was placed and held in with Ace bandages x 2.

The patient tolerated the procedure well.



34


Pathology Report

Age: 82

SourceSKIN, right ankle - basal cell carcinoma (wide excision)

Clinical InformationBasal cell carcinoma right ankle

Gross DescriptionThe specimen is received in saline and consists of a circular piece of skin andsubcutaneous tissue, measuring 3.0 cm. in diameter and 0.7 cm., in maximumthickness. The skin surface shows an ill-defined, slightly raised plaque like lesion. Itmeasures 2.0 cm in maximum dimension and is located 0.3 cm. from closet skin marginof resection. The specimen is inked. Sections; multiple, all. Blocks-4.

DiagnosisSkin and subcutis, portion of, showing basal cell carcinoma involving a focus atsuperficial papillary dermis.Sections show subepidermal fibroplasia and fibrosis.Deep reticular dermis and subcutis are negative for tumor.Melanocytic nevus, dermal type. Surgical margins of resection are free.

Electronic Signature



35


OPERATIVE REPORT

Age: 56

OPERATION: Excision of melanoma of the scalp with split thickness skin graftcoverage, donor site, left hip.

ANESTHESIA: General endotracheal anesthesia.

PREOPERATIVE DIAGNOSIS: Melanoma of scalp.

POSTOPERATIVE DIAGNOSIS: Melanoma of scalp.

OPERATIVE INDICATIONS: This patient is a middle age female, with a history ofmelanoma, lentigo maligna, over the area of the scalp in the mid occiput area.

OPERATIVE PROCEDURE: The patient was placed under general endotrachealanesthesia in the supine position, after which time the anterior scalp was prepared anddraped in a sterile fashion. The patient was then positioned in a prone position. The lefthip was also prepared and draped in a sterile fashion. A 2 cm marking was then madearound the area of desquamated melanoma site. This was then infiltratred with 0.5%lidocaine, 1:200,000 epinephrine. After adequate time for vasoconstriction,approximately 10 minutes, this was then incised with a #15 blade, and carried downto the subcutaneous fat. The vessels were then cauterized with electrocautery. Thewound was then closed utilizing a 12,000 split thickness skin graft from the leftupper thigh area. This was taken after it was measured from the surrounding region.After it was taken, the donor site was then covered with epinephrine soaked gauze,followed by bacitracin and Op-Site. The split thickness skin graft was then meshedfrom 1 to 1.5 measure, and placed over the area of the scalp, and sutured to thesurrounding scalp utilizing #4-0 chromic. Xeroform was then placed over this area,followed by a moistened fluffs dressing, and bolstered utilizing #2-0 silk. The patienttolerated the procedure well, and was sent to the recovery room in stable condition.

ESTIMATED BLOOD LOSS: Minimal.

REPLACEMENT: D5 lactated Ringer’s.

CONDITION ON DISCHARGE: Stable.



36


PATHOLOGY REPORT

FINAL DIAGNOSIS: SKIN MELANOMA SCALP, EXCISION - MALIGNANT MELANOMA. - VERTICAL DEPTH 1.1 MM, COMPLETELY EXCISED, CLARK LEVEL IV

- WITHIN A SUPERFICIAL SPREADING- MELANOMA WITH A VERTICAL GROWTH PHASE.

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

SPECIMEN(S) SUBMITTED: SKIN MEALNOMA SCALP

CLINICAL DATA: MALIGNANT MELANOMA SCALP

GROSS DESCRIPTION:A. Received fresh is a 6.0 x 6.0 x 0.3 cm irregular fragment of tan-white, hair-bearing skin. It is oriented by the surgeon with a purple suture designating“anterior”; a blue suture designating “posterior”; a black suture designating “right”;and a white suture designating “left”. Inked by the surgeon on the skin’s surface is a2.0 x 1.5 cm irregular area of tan-brown, darker discoloration. A mass is notpalpable and this area is merely slightly discolored. This region of abnormalitymeasures 1.5 cm from the anterior margin, 2.0 cm from the posterior margin, 1.5 cmfrom the right margin and 1.5 cm from the left margin. The deep margin is inkedblack. The entire margin of the specimen is shaved and submitted.

Representative sections are submitted in formalin in seven cassettes. Summary ofcassettes: A1, anterior shaved margin; A2, left shaved margin; A3, right shavedmargin; A4, posterior shaved margin; A5-A7, lesion (ink is deep margin).

(Age: 56) F



37


OPERATIVE REPORT

OPERATION: Excision of basal cell carcinoma of the right lower extremity and leftlower extremity with split-thickness skin graft to the left pretibial excision site.

ANESTHESIA: General endotracheal.

PREOPERATIVE DIAGNOSIS: Basal cell carcinoma of the left pretibial region andthe right lower pretibial region.

POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma of the left pretibial region andthe right lower pretibial region.

OPERATIVE INDICATIONS: The patient was evaluated by a dermatologist who tookbiopsies of two lesions of her lower extremities revealing basal cell carcinoma. Thelower extremities revealed significant chronic lower extremity edema from her cardiaccondition. This was considered within the preoperative plan and closure of the excisionsites was not possible. Therefore, split-thickness skin graft was planned for the large4 cm excision of the basal cell carcinoma of the left pretibial area.

OPERATIVE PROCEDURE: The patient was brought to the operating room on May18, 1999. After verification of her name and confirmation of the procedure to beperformed, adequate general endotracheal anesthesia was obtained. Her both lowerextremities and her left groin were prepped and draped in the usual sterile fashion. Bothbasal cell carcinoma areas were infiltrated using 1% lidocaine with 1:100,000epinephrine. Additionally, the left groin where the split-thickness skin graft would beharvested was also infiltrated with lidocaine with epinephrine. Because of the type ofbasal cell carcinoma, the right pretibial region was excised with a 3 mm margin. Thespecimen was sent for frozen sections and returned negative margins for tumor.The area was then closed using a series of interrupted, inverted dermal 3-0 Vicrylsutures and two retention type 3-0 Prolene sutures over bolsters in horizontal mattresstype fashion. The skin was reapproximated using interrupted 4-0 nylon sutures. Theexcision of the proximal left pretibial basal cell carcinoma was then undertaken.Because of the type of basal cell carcinoma, a 5 mm border was required. This resultedin a defect 4 cm in diameter. The skin was carefully removed from the underlyingsubcutaneous tissue not to injure the superficial vascular plexus. Epinephrine soakedsponge was used for hemostasis. The lesion was oriented and frozen sections revealedmargins free of tumor. The split-thickness skin graft was then harvested from the



38


right groin in an elliptical fashion measuring 4 x 8 cm. It was harvested in a split-thickness fashion using a #10 blade. The skin graft was then further defatted on the backtable and prepared for grafting. The incision through the full thickness of the dermis wasthen completed around the borders of the incision.

Hemostasis was assured and reapproximation was accomplished using 3-0 Vicryl and acontinuous running subcuticular 3-0 Monocryl suture. The skin graft was then appliedusing staples, Adaptic mineral oil soaked cotton and silk tie-over bolsters. The lowerextremities were then dressed using Kerlix and a compression Ace wrap beginning fromher feet to just distal to the popliteal area. This provided graded compression. The groinwound was dressed using Adaptic and Bacitracin. The patient tolerated the procedurewell and was taken to the recovery room in stable condition.

COUNTS: At the conclusion of the operation, all needle, sponge and instrument countswere correct.



39


PATHOLOGY REPORT

FINAL DIAGNOSIS:1. RIGHT PRETIBIAL SKIN, SEGMENTAL EXICSION (A) - CHANGES CONSISTENT WITH HEALING BIOPSY SITE. NEGATIVE FOR RESIDUAL BASAL CELL CARCINOMA.

2. LEFT PRETIBIAL SKIN, BIOPSY (B) - RESIDUAL BASAL CELL CARCINOMA ASSOCIATED WITH HEALING BIOPSY SITE REACTION.

Comment: The basal cell carcinoma is not identified at the inked margin ofthe specimen.

SPECIMEN(S) SUBMITTED: Part A: RIGHT PRETIBIAL Part B: LEFT PRETIBIAL

CLINICAL DATA: BCCA RT MEDIAL LE AND LT ANTERIOR PRETIBIAL REGION.

GROSS DESCRIPTION:A. Received fresh, the specimen consists of a skin-covered soft tissuesegment measuring approximately 2.2 x 0.9 x 0.2 cm. It has been oriented by thesurgeon with as short stitch designating the “superior” aspect of the specimenand a long stitch designating the “medial” aspect of the specimen. The medialskin edge is inked with yellow ink. The lateral skin edge is inked with blue ink.The deep margin is inked with black ink. No lesions are identified on the surfaceof the specimen. The specimen is submitted for frozen section consultation asfollows: 1, inferior tip; 2, superior tip; 3-5, remainder of specimen.

B. Received fresh is a single segment of skin-covered soft tissue measuring 3.0 x2.1 x 0.2 cm. It has been oriented by the surgeon with a short suturedesignating the “superior” aspect of the specimen and along sutureddesignating the “lateral” aspect of the specimen. The deep surface is inkedblack. The skin edges are inked yellow. Examination of the specimenreveals a scaly, brown-yellow lesion on the skin’s surface which measures 0.3x 0.3 x 0.1 cm. It lies 0.9 cm from the superolateral margin of the specimen,the nearest margin. No other lesions are identified.



40


Sections are submitted for frozen section as follows: 1, superior margin, perpendicular; 2, inferior margin, perpendicular, 3, lateral margin (superior aspect), perpendicular, closest margin; 4, medial margin, perpendicular; 5, remainder of grossly identifiable lesion.

INTRAOPERATIVE CONSULTATION:A. BIOPSY REPAIR REACTION. ALL MARGINS NEGATIVE.B. BASAL CELL CARCINOMA, MARGINS OF EXCISION NEGATIVE FOR TUMOR.

(Age: 76) F



41


OPERATIVE REPORT

Age: 41

OPERATION: Excisional biopsy of right lower chest wall to rule outdermatofibrosarcoma protuberans. Split thickness skin graft (100 cm square)reconstruction of wound with harvest from left anterior thigh.

ANESTHESIA: General endotracheal.

PREOPERATIVE DIAGNOSIS: Rule out recurrent dermatofibrosarcoma protuberansto a right lower chest wall.

POSTOPERATIVE DIAGNOSIS: Benign skin growth to chest wall with no evidenceof tumor recurrence.

OPERATIVE INDICATIONS: This is a very pleasant 41-year-old gentleman with aprevious resection of dermatofibrosarcoma protuberans to his right lower chest wallwith split thickness graft coverage. He was recently seen and evaluated in clinic fora small area of the wound which was nonhealing and draining with suggestion ofpossible recurrence. After lengthy discussion with the patient of risks, benefits, optionsand alternatives, he was ultimately scheduled for re-excision of the site with planned splitthickness skin graft reconstruction and presents today for such procedure.

OPERATIVE PROCEDURE: The patient was brought to the operating room andplaced in supine position. After adequate anesthesia was achieved, his chest and upperabdomen and left anterior thigh were prepared and draped in the usual sterile fashion.We began by excising this questionable area on his right lower chest wall, leavingapproximately a 1 cm border with planned total 2 cm border should the pathologysuggest recurrent tumor. The tumor was excised down to an including thesubcutaneous tissue down to identifying the chest wall. This was then marked withsutures at the superior, inferior and lateral borders for evaluation by frozen sectionpathology. Once the site was excised, this was ultimately submitted for evaluation. Theresulting frozen sections revealed no evidence of recurrent tumor. At this point, thesite was then irrigated with copious amounts of normal saline. When adequatehemostasis was achieved, we then harvested a 100 square cm skin graft from his left



42


anterior thigh without any difficulty (14 mm thickness) which was then ultimatelymeshed in a 1:1.5 pattern. This was then laid onto the site and trimmed in theappropriate fashion, tacked to the defect using multiple interrupted 5-0 chromicinterrupted sutures, followed by two running sutures to reapproximate the edges andachieve appropriate alignment.

At this point, six 2-0 silk sutures were then placed leaving the ends long to use asbolsters. The site was then irrigated with normal saline. All clots were dislodged. Atthis point, a Xeroform was then laid over the split thickness skin graft over which weplaced mineral oil and water moistened cotton gauze for use as a bolster. The purse wasthen formed and over-tied with the silk sutures using a proper tension. An ABD was thenplaced over this site and taped in place. An ABD was then placed over the left anteriorthigh split thickness skin harvest site after covering the site first with an epinephrinesoaked sponge immediately following harvest and then finally by an OpSitedressing. Once the ABD was in place this was then covered using a Kerlix. At this pointthe patient was subsequently awakened, extubated and transported in hemodynamicallystable condition to the recovery room. No acute complications were noted. Dr. Papaywas present throughout the entire course of the operation.

COUNTS: All sponge and instrument counts times two were correct.

ESTIMATED BLOOD LOSS: Normal (less than 25 cc).

SPECIMEN: Excised growth submitted for frozen section (frozen equals no evidence ofrecurrence).

DRAINS: None.

COMPLICATIONS: None.



43


PATHOLOGY REPORT

FINAL DIAGNOSIS: RIGHT CHEST WALL, PARTIAL EXCISION - HYPERTROPHIC SCAR AND MILD INFLAMMATION.

Comment: Dense fibrous connective tissue extends to the deep margin of this re-excision specimen, but this tissue is not as cellular as this patient’s previously excised dermatofibrosarcoma protuberans (S99-15311). This tissue is interrupted as hypertrophic scar rather than recurrent DFSP.

SPECIMEN(S) SUBMITTED: RIGHT CHEST WALL

CLINICAL DATA: S/P EXCISION OF DERMATOFIBROSARCOMA ANTERIOR CHEST WALL, RULE OUT DFSP.

GROSS DESCRIPTION:A. Received fresh and oriented by the surgeon, the specimen consists of an ellipseof skin and underlying subcutaneous tissue which measures 5.8 x 2.6 x 1 cm. Anulcerated nodule is present within the center of the specimen which measures 1 cmin greatest dimension. The nodule is located 1.2 cm from both the anterior andsuperior margins of resection. The deep margin of the specimen is inked with blackink. The inferior margin is inked in blue and the superior margin is inked in yellow.Cross section through the center of the nodule reveals firm, which subcutaneoustissue. A representative section of the nodule with the deep and inferior margins ofresection area submitted for frozen section evaluation. Additional sections aresubmitted in formalin under the following designations: 2) inferior-lateral shavemargin of resection; 3) inferior-medial shave margin of resection; 4) superior-medialshave margin of resection; 5) superior-lateral shave margin of resection; 6-7)remainder of ulcerated nodule.

INTRAOPERATIVE CONSULTATION:A. INFLAMED GRANULATION TISSUE WITH FIBRIN.

- NO DEFINITE NEOPLASM IN ONE REPRESENTATIVE SECTION.

(Age: 41) M



44


OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Probable basal cell carcinoma of right auricle and preuaricular skin.

POSTOPERATIVE DIAGNOSIS: Basal cell carcinoma of the auricle and preauricular skin.

NAME OF OPERATION: Wide radical excision of basal cell carcinoma from theright auricle and preauricular skin with frozen sectionand reconstruction via full thickness skin graft fromthe right anterior neck with secondary closure viasuperiorly and inferiorly based advancement flaps.

DESCRIPTION OF PROCEDURE: This very pleasant 77-year-old female was broughtto the operating room at the U.S.A. Community Hospital and placed in the dorsal supineposition. The area of her face and neck was prepped and draped with Betadine solution.Directing our attention initially to the area in question this was outlined with 4% gentianviolet getting large margins around the area. The patient had been wearing her hair tocover up this area in question. Using a Swiss bladebreaker knife and special razor, afterinfiltrating the area with 1% Xylocaine with Epinephrine, the tissue in question wasresection. Frozen section was accomplished which indicated the margins to be freecircumferentially. Subsequently, the tissues were undermined and it was felt thatsince such a large defect was present we would be unable to close this thingprimarily without distortion of the facial features including the ear, the uppereyebrow, and the lateral canthus of the orbit.

Subsequently, a portion of redundant skin from the neck was identified and anelliptical incision was made here. This tissue was then resected, hemostasis beingachieved with the judicious use of the Bovie apparatus. The skin was defatted and setaside for reimplantation in an on the auricle and the preauricular skin.Circumferential undermining was accomplished in the neck area and the flaps werewalked into excellent approximentation using a series of interrupted 4-0 undyedVicryl suture. Next layer of closure was with 6 blue Prolene in a running intradermalmanner and skin clips were on the skin surfaces.



45


Directing our attention back then to the patient’s pretemporal and preauriculararea, the full thickness skin graft was placed into position here. It was sewn intoposition with bolus fixation.

The patient, having tolerated the procedure well, was given careful written and oralinstructions regarding postoperative follow-up care and activity limitations.

Coding/Reimbursement Questions:

1. What anatomical site(s) contained the basal cell carcinoma?a. Left auricleb. Left preauricular skinc. Right auricle and preauricular skind. Anterior neck

2. How was the carcinoma treated?a. Moh’s chemosurgeryb. Laser destructionc. Debridementd. Excision/resection

3. How was the carcinoma wound defect site repaired?a. Z-plasty closureb. Double pedicle flap closurec. Advancement flap closured. Full-thickness skin graft applicatione. Split-thickness skin graft application

4. What anatomical site was the donor tissue taken from to repair the carcinoma wound defect site?

a. Right auricle and preauricular skinb. Left anterior thighc. Right anterior neckd. Scalp

5. Per CPT coding guidelines, repair of donor site for a skin graft requiring skin graft or local flaps is to be added as an additional procedure.

a. Trueb. False

Explain: _____________________________________________________________________________________________________________________________________



46

6. CPT code(s) - modifier(s): ______________________________________________



47


OPERATIVE REPORT

Age: 42

OPERATION: Mini micrografts times 250 to crown and vertex of scalp.

ANESTHESIA: Local 1% lidocaine.

PREOPERATIVE DIAGNOSIS: Male pattern baldness, Norwood classification V.

POSTOPERATIVE DIAGNOSIS: Male pattern baldness, Norwood classification V.

OPERATIVE INDICATIONS: The patient is a 42-year-old male, healthy, who hasmale pattern baldness, Norwood classification V, that extends to the posterior aspect ofthe vertex. His bald area measured approximately 18 cm from presumed hairline toocciput and 10 cm across. He requested hair transplantation procedures with minimicrograft sessions. The procedure was explained to the patient including its limitations,complications, and need for multiple stages, and he understood and decided to proceed.

OPERATIVE PROCEDURE: Under adequate local 1% lidocaine with 1:200,000epinephrine, the donor site which was taken from the right parietooccipital area wasanesthetized measuring approximately 4 cm x 1 cm and the crown was anesthetized anarea measuring approximately 5 cm x 5 cm. The donor site grafts were harvested inthree strips 2 mm in width and placed on a separate table and cut up into 250 to 270mini micrografts containing one hair and two hairs. The donor site was irrigated withsaline. Hemostasis was achieved with the electrosurgical unit and the wound wasapproximated primarily with interrupted #4-0 Monocryl and skin staples. The minimicrographs were then placed oriented toward the front in multiple random spotstimes 250. Good transplantation was achieved. The donor site and the recipient sitewere dressed with Adaptic and Bacitracin. The patient tolerated the entire procedurewell and left the operating room in satisfactory condition.



48


OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS: Chronic left diabetic foot ulcer.

POSTOPERATIVE DIAGNOSIS: Chronic left diabetic foot ulcer.

OPERATION: Application of Oasis xenograft.

ANESTHESIA: None.

BLOOD LOSS: None.

INDICATIONS: The patient is a 51-year-old gentleman with a history of insulin-dependent diabetes and a chronic left foot ulcer. He returns for placement ofanother Oasis xenograft. He, unfortunately, got the dressing quite wet a couple ofdays ago. The appropriate consents were obtained prior to the procedure.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and,while still in his hospital bed, the dressing that was put on in the office was removed. Itwas more or less saturated with dampness as a result of the patient getting it wet two daysago. The 2 x 2 gauze that was directly over the wound had the odor of Pseudomonas.There was a greenish tinge to the material on the gauze. Inspection of the ulcer itself,however, revealed no evidence of discharge. The ulcer appeared clean and wascontinuing to granulate. I could express no discharge to palpation. There was noevidence of cellulitis. The calf wounds were washed clean with alcohol, Panafil ointmentwas applied followed by a gauze dressing. The Oasis xenograft was placed directly onthe plantar foot ulcer after alcohol was used to wipe it clean. An Adaptic with woundgel was applied over the Oasis and the foot was wrapped in a sterile dressing followed byan Ace wrap.

The patient tolerated the procedure well and was taken to the recovery room.

COMPLICATIONS:



49


OPERATIVE RECORD

PREOPERATIVE DIAGNOSIS: Recurrent left carpal tunnel syndrome.

POSTOPERATIVE DIAGNOSIS: Recurrent left carpal tunnel syndrome.

OPERATIONS: Left carpal tunnel release with dermal fascial fat graft.

ANESTHESIA: General.

COMPLICATIONS: None.

POSTOPERATIVE CONDITION: Good.

FINDINGS OF PROCEDURE: Severe adhesions of the median nerve beneath thetransverse carpal ligament. Dermal fascial fat graft was performed.

INDICATIONS: The female patient is a 20+ years after a previous carpal tunnelrelease. She has recurrent symptoms bilaterally with a positive Tinel and Phalen sign.There is evidence of recurrent disease on nerve testing. She has failed conservativetreatment and is now scheduled for surgery.

PROCEDURE: The patient was taken to the operating room. After induction of generalanesthesia, a tourniquet was placed on the left arm. The left arm and left flank wereprepped and draped in the usual sterile fashion. The arm was exsanguinated with anEsmarch and the tourniquet inflated to 280mmHg.

An extended carpal tunnel incision was made by making a Bruner incision at thewrist crease and extending along the radial border of the ring finger up to the Kaplanline. The incision was taken down through subcutaneous tissue. Hemostasis obtainedwith the bipolar.

Using sharp dissection, the forearm fascia was incised exposing the median nerve. Carewas taken to make sure the nerve was not adherent to the skin, and the palm was thenopened. It was noted that there was some reformation of the transverse carpal ligament,predominantly it had previous been released. The median nerve, however, was verytightly adherent to the undersurface of the transverse carpal ligament.

Under loupe magnification proximally and distally using sharp and blunt dissection, wewere able to separate the nerve from the surrounding cicatrix. This was a difficultprocess, but we were able to do so without injuring the medial nerve.



50


Motor branch was identified. There nerve was then traced distally until it was normaltissue. It did appear that there was some previous internal neurolysis of the nerve.Proximally, we identified the palmar branch of the medial nerve.

Within the canal, there were some adhesions of the flexor tendons which were freed.There were no masses within the canal.

Based on the amount of scarring, attention was now turned to obtaining a dermalfascial fat graft. Ellipse of skin was marked out of the flank of an area 7 x 2 cm.This was infiltrated with 0.5% Marcaine plain. The skin overlying it was excised.

The underlying dermal fascial fat was now harvested with electrocautery. This waslaid in position with the fat adjacent to the nerve, and the dermis palmar-ward. Excesswas excised. It was secured to the edge of the transverse carpal ligament proximallyand distally with Vicryl suture.

The tourniquet was deflated. Hemostasis was obtained in the wound, and the woundclosed with Vicryl and nylon on the palm and Vicryl and subcuticular Monocryl in theflank. Steri-Strips and clean dressing were placed on the flank, and a splint was placedon the hand with a clean dressing.

The patient tolerated the procedure well. There were no complications.



51

ANSWER KEY:The answers below are based on the 2004 editions of the ICD-9-CM and CPT codebooks.

Skin Grafts

Exercise 1

173.7

86.3

86.69

11606 Excision, malignant lesion including margins, trunk, arms, or legs; exciseddiameter over 4.0 cm

15100 Split graft, trunk, arms, legs; first 100 sq cm or less, or one percent ofbody area of infants and children (except 15050)

Exercise 2

173.5

86.69

15100 Split graft, trunk, arms, legs; first 100 sq cm or less, or one percent of bodyarea of infants and children (except 15050)



52

Exercise 3

943.30

948.00

86.22

86.69

15000 Surgical preparation or creation of recipient site by excision of openwounds, burn eschar, or scar (including subcutaneous tissues); first 100 sqcm or one percent of body area of infants and children


Exercise 4

998.59

86.3

86.63


15220 Full thickness graft, free, including direct closure of donor site, scalp,arms, and/or legs; 20 sq cm or less



53

Exercise 5

892.1

892.0

250.00

86.22

86.22

86.67

86.67

15000 Surgical preparation or creation of recipient site by excision of openwounds, burn eschar, or scar (including subcutaneous tissues; first 100 sqcm or one percent of body area of infants and children

15000 Surgical preparation or creation of recipient site by excision of openwounds, burn eschar, or scar (including subcutaneous tissues), first 100 sqcm or one percent of body area of infants and children

15342 Application of bilaminate skin substitute/neodermis: 25 sq cm

15343 Application of bilaminate skin substitute/neodermis: each additional 25 sqcm (List separately in addition to code for primary procedure)



54

Exercise 6

943.30 948.00

86.22 86.69


15001 Surgical preparation or creation of recipient site by excision of openwounds, burn eschar, or scar (including subcutaneous tissues); or eachadditional 100 sq cm or each additional one percent of body area ofinfants and children (List separately in addition to code for primaryprocedure)




15101 Split graft, trunk, arms, legs; each additional 100 sq cm, or eachadditional one percent of body area of infants and children, or part thereof(List separately in addition to code for primary procedure)





55

Exercise 7

998.32

86.22

86.69









56

Exercise 8

945.36

948.00

86.22

86.69





57

Exercise 9

1162615120

Exercise 10

1160315100

Exercise 11

1162615120

Exercise 12

116041510011403

Exercise 13

1500015100

Exercise 14

1. c. Right auricle and preauricular skin2. d. Excision/resection3. d. Full-thickness skin graft application4. c. Right anterior neck5. a. True6. 11640-59

1526014040



58

Exercise 15

1522015221

See CPT code book, parenthetical note underneath code 15776:

“(For strip transplant, use 15220).”

Exercise 16

15400

Exercise 17

64721-LT15770

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