Question

operative report
preoperative diagnosis: squamous cell carcinoma, scalp.
postoperative diagnosis: squamous carcinoma, scalp.
procedure performed: excision of squamous cell carcinoma, scalp with yin - yang flap repair
anesthesia: local, using 4 cc of 1% lidocaine with epinephrine.
complications: none.
estimated blood loss: less than 5 cc
specimens: squamous cell carcinoma, scalp sutured at 12 oclock, anterior tip
indications for surgery: the patient is a 43 - year - old male patient with a biopsy proven squamous cell carcinoma of his scalp measuring 2.1 cm. i marked the area for excision with gross normal margins of 4 mm and i drew my planned yin - yang flap closure. the patient observed these markings in two mirrors, to understand the surgery and he agreed on the location. we proceeded with the procedure.

• description of procedure: the area was infiltrated with local anesthetic. the patient was placed prone, his scalp and face were prepped and draped in sterile fashion. i excised the lesion as drawn to include the galea. hemostasis was achieved with the bovie cautery. pathologic analysis showed the margins to be clear. i incised the yin - yang flaps and elevated them with the underlying galea. hemostasis was achieved in the donor site using bovie cautery. the flap rotated into the defect with total measurements of 2.9 cm x 3.2 cm. the donor sites were closed and the flaps inset in layers using 4 - 0 monocryl and the skin stapler. loupe magnification was used. the patient tolerated the procedure well.

what cpt® and icd - 10 - cm codes are reported?
14040 c44.42
14020 c44.42
14041 c44.49
14000 c43.99

Explanation:

The CPT code 14040 is used for excision of a lesion with a flap repair. Here, squamous cell carcinoma of the scalp was excised with a Yin - Yang flap repair which aligns with 14040. The ICD - 10 - CM code C44.42 is for malignant neoplasm of skin of scalp and neck. Since the diagnosis is squamous cell carcinoma of the scalp, this ICD - 10 - CM code is appropriate.

Answer:

14040, C44.42