# Excision Perineal mass CPT



## jdibble (Nov 18, 2013)

Any help with a code for this procedure would be greatly appreciated!

PREOPERATIVE DIAGNOSIS:  Perineal mass.

POSTOPERATIVE DIAGNOSIS:  Perineal mass.

PROCEDURE:  Examination under anesthesia, excisional biopsy of right perineal
body mass.

ANESTHESIA:  General endotracheal.

INDICATIONS:  The patient is a 42-year-old female, found to have a hard
fibrous mass in the perineal area.  The patient had a workup which included a
CT scan and an ultrasound which suggested infection.  The lesion did not
respond to antibiotics and the patient was scheduled then for an exam under
anesthesia, with a biopsy of this area.

PROCEDURE IN DETAIL:  The patient was given IV antibiotics.  The patient had
Venodynes in place.  She was brought to the operating room and was placed on
the OR table in the supine position.  The patient was given anesthesia via an
endotracheal route.  The patient was then placed into lithotomy position with
exposure of the perineal area.  The perineal area was prepped and draped in
the usual sterile fashion and a time-out was performed.  

The patient was found to have a hard mass just inferior and lateral to the labia in the area of the perineum on the right.  An oblique incision was created over this firm area
after infiltration with Marcaine at a concentration of 0.5%.  Dissection was
continued down to the mass.  The mass was excised and sent to Pathology for
frozen section.  There was a small amount of granulation tissue, which was seen
and this was curetted.  The wound was then irrigated and closed in several
layers of 3-0 Vicryl.  The skin was closed with 3-0 chromic and Dermabond was
applied.  The patient was placed back into a supine position, and a frozen
section revealed this to be a benign process.  The sponge, instrument and lap
counts were correct at the conclusion of the procedure.  The patient was awakened and was taken to the recovery area with stable vital signs.

Thanks!


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## sscott@hogonc.com (Jan 18, 2019)

Did you get any responses to this?


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## csperoni (Jan 18, 2019)

I would look into the 11000 series codes.  
Depending on the size, 11400-11406 since it indicates pathology was benign.  
Of note, the provider indicates LAYERED closure, so you may bill separately for the intermediate wound closure 12031-12037


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