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 o’clock, anterior tip
indications for surgery: the patient is a 43-year-old white man with a biopsy-proven basosquamous 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, so he can understand the surgery and agreed on the location and we proceeded.
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?