Wide Local Excision for Melanoma
1160338500wRVU: 3.7 — Sentinel lymph node biopsy (open, if performed at same session)38792wRVU: 0.63 — Injection of radioactive tracer for lymph node identification12032wRVU: 2.46 — Intermediate repair, trunk/extremity 2.6-7.5 cm (if layered closure)
Melanoma, [location], [Breslow thickness X mm, [Clark level X], [ulceration present / absent]
Same
Wide local excision, [location], [X] cm margins, with primary closure [/ advancement flap / skin graft]
[Attending name], MD
[Resident name]
[Local with sedation / General]
Patient presents with biopsy-confirmed melanoma at [location], Breslow thickness [X] mm, [Clark level X], [with / without] ulceration. [Sentinel lymph node biopsy planned concurrently.] Per NCCN guidelines, [1 cm / 2 cm] margins indicated. Risks including recurrence, wound complications, and lymphedema (if SLNB) discussed. Consent obtained.
Biopsy scar at [location] with [visible / non-visible] residual pigment. [Sentinel lymph node biopsy: [X] nodes retrieved from [axilla / groin / neck], [sent for frozen section / permanent pathology].] Margins: [X] cm achieved on all sides.
[SENTINEL LYMPH NODE BIOPSY, if performed:] Radiocolloid [Technetium-99m sulfur colloid] was injected [preoperatively in nuclear medicine / at start of case] around the biopsy site. Gamma probe used to map lymphatic drainage to [right axilla / left groin / neck]. [Isosulfan blue / methylene blue dye injected peritumorally.] The sentinel node basin was incised and dissected; [X] hot and/or blue node(s) identified and removed. Sent for [frozen section: [negative / positive] / permanent pathology].
WLE: A [1 cm / 2 cm] margin was marked circumferentially around the biopsy scar or visible lesion using a surgical marker. An elliptical excision was designed to facilitate primary closure. Local anesthetic infiltrated. The excision was carried down to [deep dermis / subcutaneous fat / superficial fascia] with [scalpel / electrocautery]. The specimen was oriented with sutures ([long = lateral, short = superior / per surgeon convention]) and sent to pathology.
Hemostasis achieved. Closure: [primary closure with [3-0 Vicryl] deep dermis and [4-0 Monocryl] skin / advancement flap / split-thickness skin graft]. Sterile dressing applied. Patient tolerated the procedure well.
None
WLE specimen to pathology with orientation sutures. [Sentinel lymph node(s) labeled individually and sent to pathology.]
Minimal
None
Patient to PACU. Discharged home.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Melanoma, ***, Breslow *** mm, [ulcerated / non-ulcerated]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Wide local excision, ***, *** cm margins, [primary closure / flap / graft]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [Local with sedation / General]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with biopsy-confirmed melanoma at *** (Breslow *** mm, [ulcerated / non-ulcerated]). [Concurrent SLNB planned.] NCCN-guided *** cm margins indicated. Risks discussed. Informed consent obtained.
FINDINGS: Biopsy scar at *** with [visible pigment / scar only]. [SLNB: *** nodes from [axilla / groin] retrieved, sent to pathology.] WLE margins *** cm achieved.
DESCRIPTION OF PROCEDURE:
[SLNB: Radiocolloid injected preoperatively in nuclear medicine. Gamma probe mapped drainage to [axilla / groin]. [Blue dye injected peritumorally.] Sentinel basin incised; *** hot/blue node(s) identified and removed; sent to [frozen section: *** / permanent pathology].] WLE: *** cm margin marked circumferentially around biopsy scar. Elliptical excision designed. Incision to [subcutaneous fat / superficial fascia]. Specimen oriented [long = lateral, short = superior] and sent to pathology. Hemostasis. Closure: [primary with 3-0 Vicryl deep and 4-0 Monocryl skin / flap / STSG]. Dressing applied. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: WLE to pathology (oriented). [Sentinel nodes individually labeled to pathology.]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU. Discharged home.
Signed: .ME, .MYDEGREE
.TODAYVariants
Head and neck melanoma
Lymphatic drainage patterns are unpredictable. Sentinel node mapping critical. Facial closure often requires local flap or complex repair. Parotid involvement may require parotidectomy.
Completion lymph node dissection (CLND)
Now performed selectively (after DeCOG and MSLT-II trials). Bill 38745 (axillary), 38765 (inguinal). Document nodal yield, ECE status, and number of positive nodes.
Charting Tips
- State Breslow thickness and ulceration from biopsy report, as these determine margin width
- Document final surgical margin size achieved (not just planned)
- Orient specimen with sutures and document convention (long = lateral is standard)
- Note sentinel node technique (tracer type, injection site, gamma probe counts, blue dye)
- Document frozen section results if performed intraoperatively
Billing Tips
- Bill 11600-11606 for excision of malignant skin lesion by size of the excised defect (including margins). 11602: trunk/extremity 1.1-2.0 cm (3.51 wRVU); 11603: 2.1-3.0 cm (4.35 wRVU); 11604: 3.1-4.0 cm (5.18 wRVU). The defect size (not the tumor size) determines the code. Measure the final excised specimen.
- Repair codes are separately billable in addition to excision. Simple closure is included in the excision code. Intermediate or complex closure (layered) uses 12031-12057 (intermediate) or 13100-13160 (complex). Skin graft or flap reconstruction uses graft/flap codes separately.
- Sentinel lymph node biopsy (SLNB) at the same session: bill 38500 (open SLNB, 6.12 wRVU) or 38792 (injection of radioactive tracer, 1.38 wRVU). SLNB and WLE on the same day are not bundled. Bill both and document isotope injection and gamma probe use.
- Lymphadenectomy (completion CLND after positive SLNB): bill 38745 (axillary), 38765 (inguinal), or 38780 (retroperitoneal/iliac). These are separate from the WLE and SLNB codes.
- 90-day global: routine wound checks and suture removal are bundled. Re-excision for positive margins within 90 days uses modifier -78.