# Multiple lipomas



## trinalankford

This patient had multiple lipomas removed, and I'd like to check on these codes and whether lipomas are ALWAYS coded to musculoskeletal and not integumentary.....

Postop dxs:
1) 3 cm left thigh lipoma.  27327
2) 2 cm left arm lipoma.  25075-59-LT
3) 1.5 cm right flank lipoma.   21930-59
4) 1 cm right forearm lipoma.   25075-59-RT
5) 1 cm left lumbar lipoma.   27047-59

Op note: (in outpatient surgery) The sites were reviewed and marked with marking pen. The areas were individually prepped with ChlorPrep. The first site was with the patient in the right lateral decubitus position. The lesions on the left lumbar and left upper thigh laterally were draped off. The skin incisions were infiltrated with Xylocaine with epi. Skin incisions were made. They were of the same length as described above. Dissection was carried out in the superficial subcutaneous tissues in each case, identifying multilobulated lipoma in the thigh and a more-or-less intact lipoma in the left lumbar. Pinpoint cautery was used for hemostasis. After excising, the wounds were closed with subcutaneous and subcuticular 4-0 Vicryl followed by Steri-Strips. The patient was then placed in supine. The left arm had a 2 cm lipoma on the ulnar aspect. It was prepped and draped, infiltrated, and incised and treated in the same manner as the previous two lesions. The lesion on the right arm was smaller, being only 1 cm in size, located more on the extensor aspect of the mid forearm. The patient was then placed in left lateral decubitus to approach the 1.3 cm lesion on the right flank. All lesions were excised in the same manner, closed with the same suture technique, and covered with sterile dressings.

NOTE: Path on all was angiolipoma/lipoma.

Thank you for your help.


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## missy874

You might find this helpful from CPT assistant April 2010:
	Integumentary vs Musculoskeletal Lesion Excisions
******CPT Assistant, April 2010 Page: 3,4,11 Category:  
******Related Information 

Integumentary vs Musculoskeletal Lesion Excisions 

There is often confusion in determining whether the excision of soft tissue tumors is reported with codes from the integumentary system or the musculoskeletal system. To dispel this ambiguity, new codes and guidelines have been established for the integumentary and musculoskeletal system in the CPT 2010 codebook. This article will provide an overview on the different types of lesion excisions in the integumentary and musculoskeletal systems, as well as describe the additions and revisions to these codes and guidelines. 

Review of Skin Anatomy 

Skin, the body's largest organ system, includes the epidermis (thinner outer layer) and the dermis (thicker inner layer). Below the dermis is the subcutaneous tissue, then the fascia, which is the layer between the subcutaneous tissue and the underlying muscle. Lesions deep to the skin may occur in the soft tissue, deep subcutaneous plane, subfascial (below the fascia), intramuscular (into the muscle), or submuscular (below the muscle). 

Integumentary System Guidelines 

Guidelines for the excision of integumentary lesions have been clarified in CPT 2010. 

Simple closures are included in the excision of benign and malignant skin lesions. If an intermediate closure (codes 12031-12057) or complex closure (codes 13100-13153) is required, it should be separately reported. When reconstructive closures are required, they are separately reported with codes 15002-15261 and 15570-15770. 

The following are the three repair (closure) definitions:  

·Simple repair: used when the wound is superficial; eg, involving primarily epidermis, dermis, and subcutaneous tissue and no deeper structures. The wound closure involves closing one layer, and includes local anesthesia, and chemical or electrocauterization of unclosed wounds. 

·Intermediate repair: includes requires layered closure of one or more of the deeper layers of subcutaneous tissue and superficial (nonmuscle) fascia. Single-layer closure of heavily contaminated wounds, which required extensive cleaning or removal of particulate matter also constitutes as intermediate repair. 

·Complex repair: requires more than layered closure, such as scar revision, debridement (eg, traumatic lacerations or avulsions), extensive undermining, stents or retention sutures. Necessary preparation includes creation of a defect for repairs (eg, excision of a scar requiring a complex repair) or the debridement of complicated lacerations or avulsions. 

Integumentary Lesion Excisions 

The Integumentary System guidelines listed in the CPT 2010 codebook define an excision as the removal of a lesion, including margins, through the full thickness of the dermis, and including simple (nonlayered) closure and local anesthesia. Code selection is determined by measuring the greatest clinical diameter of the apparent lesion, plus the margin required for complete excision, prior to the procedure. Integumentary excision procedures may require simple, intermediate, or complex closures. Simple repair is included in the lesion excision and is not reported separately. However, repair by intermediate or complex closures should be reported separately. For example, if a malignant skin lesion on the left arm measuring 1.0 cm is excised with 0.3cm margins (excised diameter 1.6 cm), and requires a complex closure of the wound of 3.0cm length after accounting for manipulation of the wound for closure, report CPT code 11602, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm, for the excision; for the repair, report code 13121, Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm. 

Note that when the excision of benign or malignant skin lesions (codes 11400-11446 and 11600-11646) is performed in conjunction with an adjacent tissue transfer (codes 14000-14302), only the adjacent tissue transfer should be reported, as the excision is included in this procedure. 

New Musculoskeletal System Guidelines 

Whether reporting the excision or radical resection of soft tissue tumors from the subcutaneous, fascial or subfascial layer, appreciable vessel exploration and/or neuroplasty should be reported separately. Simple and intermediate repair closures are included in the excision procedures, but if complex repairs with extensive undermining or other techniques are performed to close a defect created by a lesion excision, the complex repair codes are reported separately. The excision of musculoskeletal lesions (tumors), includes the dissection or elevation of tissue planes in order to allow resection of the tumor, and therefore, those services are not reported separately. The code selection for musculoskeletal lesion excisions is determined by measuring the greatest diameter of the tumor, in addition to the narrowest margin required for the complete excision of the tumor, based on the physician's judgment, at the time of the excision. The radical resection of soft tissue tumors may be confined to a specific layer, for instance the subcutaneous or subfascial tissue, or it may involve the removal of tissue from one or more layers. Radical resection of soft tissue tumors is most commonly used for malignant or very aggressive benign tumors.  

Musculoskeletal Lesion Excisions 

Musculoskeletal lesion excision codes pertain to subcutaneous, superficial, or deep soft tissues under the skin, which may include subcutaneous fat, fascia, muscle and bone. Soft tissue excision codes are dispersed throughout the CPT 2010 musculoskeletal section and are categorized by anatomic site.  

When coding musculoskeletal procedures, it is important to note that the excision must meet the criteria listed in the code descriptor. For example, in order to report code 26116, Excision, tumor, soft tissue, or vascular malformation, of hand or finger; subfascial (eg,intramuscular); less than 1.5 cm, the tumor must be down to the muscle (ie, located between the fascia and muscle) or be intramuscular, such as a muscle sarcoma. 

Coding Tip 

For radical resection of tumors of cutaneous origin (eg, melanoma), report the appropriate code from the 11600-11646 series. Appropriate code choice is based on the measurement of the tumor plus its margin made at the time of excision. 

The physician must determine the depth of the excision in order to ascertain whether the integumentary system or musculoskeletal system CPT codes are appropriate. Documentation must reflect what is being performed, in order to substantiate the selection of these codes. 

Coding Tip 

For radical tumor resection, neuroplasty and reconstructive procedures (eg, adjacent tissue transfer, flap) should be reported in addition to the excision code. 

The following are the different types of excisions, as listed in the guidelines: 

·Subcutaneous soft tissue tumors: involve the simple or marginal resection of tumors confined to subcutaneous fatty tissue below the skin, but above the deep fascia. 

·Fascial or subfascial soft tissue tumors: involve the resection of tumors confined to the tissue within or below the deep fascia, but not involving the muscle or bone. Included are digital (ie, fingers and toes) subfascial tumors that involve the tendons, tendon sheaths, or joints of the digit. 

·Radical resection of soft tissue tumors: involve the resection of a tumor, usually malignant, with wide margins of normal tissue. 

·Radical resection of bone tumors: involve the resection of the tumor with wide margins of normal tissue. Radical resection of bone tumors is usually performed for malignant tumors or very aggressive tumors. (See CPT Assistant February 2010.) 

Frequently Asked Questions  

Question:  

A deep subcutaneous mass (ie, not subfascial) requiring a resection of less than 3cm diameter in the posterior aspect of the left ankle is excised. Would the integumentary lesion excision code series 11400-11471 or 11600-11646 be reported? 

Answer: 

No. The 11400-11471 and 11600-11646 series of codes (benign and malignant integumentary lesion excisions) describe excisions of cutaneous lesions, as well as superficial subcutaneous lesions such as cysts and scars.  

When the lesions are located in deep subfascial or submuscular tissues, the appropriate code from the Musculoskeletal System should be reported to describe the procedure. Therefore, code 27618, Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less than 3 cm, should be reported for the excision of this deep subcutaneous mass in the posterior aspect of the left ankle. 

Question:  

May I report code 19260, Excision of chest wall tumor including ribs with Modifier 52 appended,*if the excision of a 10cm chest wall mass did not include removing the*ribs?  

Answer:  

No. It would not be appropriate to report code 19260, Excision of chest wall tumor including ribs, with Modifier 52 appended, as the procedure did not involve removal of the ribs. If the procedure involves removing a chest wall tumor without the ribs, it would be more appropriate to report a musculoskeletal tumor excision code, such as code 21557, Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck or anterior thorax; less than 5 cm, depending on the depth, size, and malignant or benign nature of the lesion.  

Question:  

What would be the appropriate CPT code for excision of a sebaceous cyst on the scalp or on the face that is subdermal or deeper?  

Answer:  

Integumentary lesion excision codes pertain to the epidermis, dermis, and subcutaneous tissue, while musculoskeletal lesion excision codes pertain to subcutaneous, superficial or deep soft tissues. Code ranges 11400-11446 and 11600-11646 represent lesions that normally occur on the surface of the skin (epidermis) or near the surface of the skin (dermis), compared to the type of lesion (or tumor) that occurs in the subfascial or fascial tissue, muscles and joints, as listed in the musculoskeletal section. A sebaceous cyst is a skin lesion and may be very large, distending the skin and pushing into the subcutaneous fatty tissue, but it is a skin lesion, and therefore, should be coded using the integumentary lesion excision codes, depending on the size of the cyst. 

Code range 21011-21016 lists the excision codes for soft tissue tumors subcutaneous and subfascial on the face or scalp. When coding musculoskeletal procedures, it is important to note that the excision must meet the criteria listed in the code descriptor. The physician must determine and document the depth of the excision to determine whether the integumentary system or musculoskeletal system CPT codes are appropriate.  

Terms Defined  

Subcutaneous soft tissue tumors: usually benign and resected without removing a significant amount of surrounding normal tissue.  

Fascial or subfascial soft tissue tumors: usually benign, involve fascia and/or muscle, and resected without removing a significant amount of surrounding normal tissue.  

Digital (ie, fingers and toes) subcutaneous tumors: adjacent to but not breaching the tendon, tendon sheath, or joint capsule. 

Digital (ie, fingers and toes) fascial or subfascial tumors: involve the tendon, tendon sheath, or joint capsule. 

Radical resection of soft tissue tumors: most commonly used for malignant tumors, and extremely aggressive benign tumors in which wide margins of normal tissue are excised. 




CPT Assistant*©*Copyright 1990-2011, American Medical Association. All rights reserved.


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## trinalankford

Thank you for your help. I think I've read every document out there right now pertaining to lipoma removals. I'll check this one out. Thanks again.


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## FTessaBartels

*Watch your font color*

Melissa ...  Please use a different color to highlight the section you currently have in yellow. It is totally unreadable against a white background.  Red or Blue work well.

Thank you.

F Tessa Bartels, CPC, CEMC


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## cmartin

The one in the thigh should actually be 27337 (3 cm OR greater) rather than 27327 (less than 3cm). For the 2 in the forearms I would use 25075-50. The other two I would code both as 21930's (when my guys say lumbar area, they're referring to the lower back), so one of them might need a -59 on it. I hope I didn't mess up the numbers, I'm cross-eyed from trying to find that missing section in my 2012 book by locating the surrounding words! Since they added all the soft-tissue tumor codes a couple years ago, the only time you'd be using 114's for a lipoma would be the rare occasion of one primarily involving the skin. I've been doing this a long time and I've only seen a couple of those.


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## trinalankford

Thank you, cmartin! Yes, that makes a lot of sense.


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