Question

Audit Report 5.3 Operative Report, Carcinoma Lower Lip

LOCATION: Inpatient, Hospital

PATIENT: Lary Montiff

SURGEON: Mark Erickson, MD

PREOPERATIVE DIAGNOSES:

1. Squamous cell carcinoma, left lower lip 

2. Submental and submandibular area mass

POSTOPERATIVE DIAGNOSES: Same

PROCEDURE PERFORMED

1. Excision of squamous cell carcinoma in skin of the left lower lip, 3.25 cm

   2. Suprahyoid neck dissection 

   3. Bilateral advancement tap closure of surgical defect, 16 square cm

ANESTHESIA: Local with IV sedation

ESTIMATED BLOOD LOSS: Less than 25 ccs

INDICATIONS: A 70-year-old male with a mass on the submental and submandibular areas. He has a recurrent squamous cell carcinoma with palpable mass in the submental area and patient is now bare fur definitive review and surgery.

DESCRIPTION OF PROCEDURE: After consent was obtained, the patient was taken to the operating room and placed in the operating room table in the supine position. After an adequate level of IV sedation was obtained, the patients lower face and neck were prepped with Betadine and then draped in a sterile manner. The incision was outlined in the lower lip area down to the mental crease area, An incision was also marked on the upper neck in the medial aspect just above the hyoid bone. The incision was extended also to the left submandibular area. The area was then infiltrated with Ice of Xylocaine with 1:100.000 units of epinephrine.

Ameniton was first focused on the lip. Utilizing sharp dissection full thickness easier was accomplished to include mucosa and skin. Three-mm margins on each side were utilized Frozen section reported squamous cell carcinoma completely excised with negative margins At the time that frozen 15ection was being done, the neck was addressed Sharp dissection was came down to the skin and subcutaneous tissue Superior and inferior suplatysmal flaps were elevated. The lymphoid tissue in the suprahyanid area extending from the submental area to the left proximal submandibular and was then dissected and removed along with the masses. Dissociation was carried down to the digastric muscle fascia. Hemostasis was achieved with silk ties and bipolar cautery. That area was sprayed with HemaSeal and then the wound was closed with the deeper tissue approximated with interrupted 4-0 Vicryl suture and the skin approximated with Bacitracin ointment and a dressing were applied.

Attention was then refocused on the lip. Bilateral advancement flaps developed again by extending the incision along the mental craane The mucosa was left intact The flaps were approximated with interest 4-0 Vicryl suture; 4-0 Vicryl suture was then utilized ie interrupted me clasure fashion to close the mucocutaneous area of the lower lip, as the mucosa. The skin was approximated with interrupted closure of 6-0 nylon. Bacitracin ointment was then applied. The patient toleratedt theprocedure well. There was no break in technique. The patient was awakened and taken to the postanesthesia care unit in good condition.

One of the following codes is reported incorrectly for this cate Indicate the incorrect code.

PROFESSIONAL SERVICES: Suprahyoid neck dissection, 38700; Bilateral advancement flaps, 14060-51; Excision of left lower lip lesion, 11644-51

ICD-10-CM DX: Neck mass, R22.1; Squamous cell carcinoma of the skin of the lip, C44.02

INCORRECT CODE:

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