Operative Report Pre-Operative and Post-Operative ...

AAPC - Final Exam Test

Question Number 35

Operative Report Pre-Operative and Post-Operative Diagnosis: Squamous cell carcinoma, left leg Open wound, right leg Personal history of squamous cell carcinoma, right leg INDICATIONS FOR SURGERY: The patient is an 81 year-old white man with biopsy-proven squamous cell carcinoma of his left leg. I marked the areas for excision with gross normal margins of 5 mm, and I drew my planned skin graft donor site from his left lateral thigh. He also had an open wound of his right leg from a squamous cell carcinoma excised four months ago; the skin graft had not taken. We plan on re-skin grafting the area. The patient is aware of all of these markings, and understands the surgery and location. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. IV Ancef was given. I used plain lidocaine for his local anesthetic throughout the procedure until the skin grafts were inset. The anterior of his leg and the thigh were infiltrated with local anesthetic. Both lower extremities were prepped and draped circumferentially, which included the left thigh on the left side. I excised the lesion on his left leg as drawn into the subcutaneous fat. Hemostasis achieved with the Bovie cautery. I then excised the wound on his right leg to lower the bacterial counts. I took a 1-2 mm margin around the wound and excised the granulation tissue as well. Hemostasis was achieved using the Bovie cautery. I then changed gloves. A split-thickness skin graft was harvested from the left thigh using the Zimmer dermatome. This was meshed 1:5:1. By this time, the pathology returned showing the margins were clear. Skin grafts were inset on each leg wound using the skin stapler. Xeroform and gauze bolster was placed over the skin graft using 4-0 nylon. The skin graft donor site was dressed with OpSite. The legs were further dressed with heavy cast padding and the double Ace wrap. The patient tolerated the procedure well. PROCEDURES: Excision squamous cell carcinoma, left leg with excised diameter of 2.5 cm, repaired with a split-thickness skin graft measuring 5.1 cm². Excisional preparation of right leg wound repaired with a split-thickness skin graft measuring 3.2 cm². What CPT® codes are reported?

a. 15100, 11603-51-LT, 15002-51-RT

b. 15100, 11403-51-LT, 15100-51-RT

c. 15100, 11603-51-LT

d. 15100, 15100-51-LT, 11603-51-LT, 15002-51-RT

✔ Correct Answer:

d. 15100, 15100-51-LT, 11603-51-LT, 15002-51-RT

AAPC - Final Exam Test

Question Number 35

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