Question

Principal Diagnosis: Epidermoid nevus of scalp Procedure

Performed: Shave excision of 4.0-cm benign scalp lesion Description
of Procedure: The patient was brought to the operating room and
made comfor

Answer 1

The principal diagnosis for this case is an epidermoid nevus of the scalp. The procedure performed was a shave excision of a 4.0-cm benign scalp lesion.

Step-by-step explanation:

The principal diagnosis, epidermoid nevus of the scalp, refers to a benign growth on the skin that is typically present from birth. In this case, the patient underwent a shave excision procedure to remove a 4.0-cm lesion on the scalp. Shave excision is a common dermatological procedure involving the removal of a superficial skin lesion using a scalpel or similar instrument.

In coding medical procedures, accurate documentation is crucial for proper billing and classification. The International Classification of Diseases, 10th Edition (ICD-10), provides codes for diagnoses, and the Current Procedural Terminology (CPT) codes are used to report procedures. The CPT code for a shave excision of a benign lesion varies based on factors such as lesion size and location. For instance, CPT code 11301 is used for the removal of benign lesions measuring 4.0 cm or larger.

Understanding the terminology and codes in medical documentation is essential for medical coders to accurately convey the patient's condition and the procedures performed. This ensures proper reimbursement for healthcare providers and contributes to accurate health records for patient care continuity.

Answer 2

The question is about a shave excision, a surgical procedure to remove a benign skin lesion from the scalp. This medical procedure is commonly performed under local anesthesia and involves removing the lesion without deep incisions.

Step-by-step explanation:

The student's question pertains to a medical procedure, specifically a shave excision of an epidermoid nevus on the scalp. An epidermoid nevus is a type of skin lesion that is typically benign, meaning it's not cancerous. The shave excision is a surgical procedure where the lesion is carefully removed using a sharp instrument, often a scalpel, without cutting deeply into the skin layers.

For a lesion that is 4.0 cm in size, the process involves numbing the area with local anesthesia, ensuring patient comfort, and then shaving the lesion off the scalp. It's a common practice for benign skin conditions where complete excision isn't required. After the procedure, the wound care instructions are given, and the lesion is typically sent to a lab for histopathological examination to confirm it's benign.