Overview of CPT Code 15958: Excision of skin lesion, malignant, face, ears, scalp, neck
CPT Code 15958 refers to the surgical excision of malignant skin lesions located on the face, ears, scalp, or neck. This procedure is performed to remove cancerous growths and prevent the spread of malignancy.
When CPT Code 15958 is Used?
This code is applicable in various clinical scenarios.
- Presence of a malignant skin lesion on the face, ears, scalp, or neck.
- Lesions that have been confirmed as cancerous through biopsy.
- Lesions that are symptomatic, such as causing pain or discomfort.
- Lesions that are growing or changing in appearance.
Symptoms Indicating This Procedure
Patients may report several symptoms that warrant this procedure.
- A new growth or sore that does not heal.
- Changes in the appearance of an existing mole or skin lesion.
- Itching, tenderness, or pain in the area of the lesion.
- Bleeding or oozing from the lesion.
Causes and Risk Factors
Understanding the causes and risk factors can help in prevention.
- Excessive sun exposure leading to skin damage.
- History of skin cancer in the patient or family.
- Weakened immune system due to conditions like HIV or medications.
- Fair skin, light hair, and light eyes, which are more susceptible to UV damage.
Diagnostic Tests Before Procedure
Certain tests may be conducted to confirm the diagnosis.
- Skin biopsy to confirm malignancy.
- Imaging studies like ultrasound if deeper tissue involvement is suspected.
- Dermatoscopy to evaluate the lesion's characteristics.
Procedure Description
The excision procedure follows a systematic approach.
- Patient is positioned comfortably and the area is cleaned.
- Local anesthesia is administered to numb the area.
- The surgeon excises the malignant lesion along with a margin of healthy tissue.
- The wound is closed with sutures or adhesive strips.
- Post-operative care instructions are provided.
Preparation for the Procedure
Proper preparation is essential for a smooth procedure.
- Avoid blood thinners like aspirin or ibuprofen a week prior.
- Inform the doctor about any allergies or medications.
- Arrive with clean skin, free of lotions or makeup.
- Arrange for transportation if sedation is used.
Recovery and Aftercare
Recovery varies, but general guidelines apply.
- Wound care includes keeping the area clean and dry.
- Follow-up appointments to monitor healing.
- Pain management with prescribed medications as needed.
- Avoid sun exposure on the healing site.
Possible Complications
While complications are rare, they can occur.
- Infection at the surgical site.
- Scarring or changes in skin texture.
- Recurrence of the malignant lesion.
- Delayed healing or wound dehiscence.
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Post-Procedure Follow-Up
Follow-up is crucial for monitoring recovery.
- Initial follow-up within 1-2 weeks post-surgery.
- Regular skin checks every 3-6 months for high-risk patients.
- Long-term monitoring for signs of recurrence.
Alternative Treatments
Non-surgical options may be considered in certain cases.
- Topical chemotherapy for superficial skin cancers.
- Cryotherapy to freeze and destroy abnormal cells.
- Photodynamic therapy using light to treat cancerous cells.
Home Care Tips
Simple tips can aid in recovery.
- Keep the surgical site clean and dry.
- Change dressings as instructed by the healthcare provider.
- Monitor for signs of infection such as increased redness or discharge.
- Avoid strenuous activities that may stress the wound.
Patient Education & Prevention
Education is key to prevention and early detection.
- Regular skin checks for new or changing lesions.
- Use sunscreen with a high SPF to protect against UV rays.
- Wear protective clothing and hats when outdoors.
- Avoid tanning beds and excessive sun exposure.
Billing and Coding Information
CPT Code: 15958
Category: Surgery
Common Modifiers:
- 50 - Bilateral procedure
- RT - Right side
- LT - Left side
Average Cost and Insurance Coverage
Costs can vary based on several factors.
- Average cost ranges from $500 to $3,000 depending on complexity.
- Most insurance plans cover the procedure if deemed medically necessary.
- Out-of-pocket costs may apply depending on the insurance policy.
Related CPT Codes
- 11400 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
- 11401 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
- 11402 - Excision, benign skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
- 11600 - Excision, malignant skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
- 11601 - Excision, malignant skin lesion, face, ears, scalp, neck; excised diameter over 4.0 cm.
References and Sources
Frequently Asked Questions (FAQs)
What is the purpose of this procedure?
The procedure aims to remove malignant skin lesions to prevent cancer spread.
How long does the procedure take?
The excision typically takes about 30 minutes to an hour.
Will there be scarring after the procedure?
Some scarring is possible, but techniques are used to minimize it.
How soon can I return to normal activities?
Most patients can resume normal activities within a few days.
