The provider documentation supported below statement. IS this considered complex repair and removal of excision or flap code.
Finally, the patient was repositioned for excision of the upper back basal cell carcinoma. The area was prepped with Betadine and draped in a sterile fashion. A #15 blade scalpel was used to make the incision through the full thickness of the skin in the elliptical pattern around the lesion. The specimen was then sharply excised at the level of the subcutaneous fat The wound edges were undermined to allow for advancement of the skin flaps.The specimen was passed off of the surgical field for transport to pathology. Hemostasis was achieved. A 4-0 polysorb suture was used in a buried, interrupted fashion to bring the dermal edges together. Once the edges were in excellent proximity, a 4-0 nylon suture was used in a simple, running fashion to close and slightly evert the skin edges. The wound closed very nicely, and the site was cleaned with saline and dried. Steri-Strips and a coverlet dressing were applied.
The excision was done for the removal of a malignant lesion 11600-11606 (Code selection is determined by the excised diameter) Depending on the diameter size, it may also determine if the closure is included.
The AMA guidelines state that an excision is defined as full thickness. The documentation is not clear, it could just be a simple repair!?!?
The undermining could mean COMPLEX, but skin flaps were done, what kind of skin flap?
There is not enough information to correctly code from this note.