# Help! Coding this Op report.



## ksamples (May 6, 2009)

Operation Performed: Left inguinal exploration and excision of lipoma. 

A transverse inguinal incision was then made. This was carried to the subcutaneous tissues. I then placed one finger into the inguinal area via the scrotum. I pushed up the mass which had been quite tender and incised over that. It actually turned out to be a lipoma which was excised. Hemostasis was ensured using cautery. 

I just need a code for the left inguinal exploration. 

Any suggestions! Thanks.


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## FTessaBartels (May 6, 2009)

*Excision only*

NOT my area of expertise, BUT ...

If this is all the op report, I'd code the excision of lipoma ONLY.

F Tessa Bartels, CPC, CEMC


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## stroie (May 6, 2009)

*inguinal exploration*

see cpt code 54550 for exploration and 54512 for excision of  lipoma.


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## coderguy1939 (May 7, 2009)

The op note is a little unclear as to where the lipoma excision was made.  If the lipoma is located on the spermatic cord you could consider 55520.


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## ksamples (May 11, 2009)

*Help! Coding this Operative Report*

Code 54560 is for undescended testis and that wasn't the reason for the exploration. I have a code for the excision of the Lipoma which was located anterior to the spermatic cord and distal to the external ring. I am just really confused on the Left Inguinal Exploration. I am leaning towards just coding for the excision of the Lipoma. Thanks so much for your comments and anything further would be appreciated.


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## coderguy1939 (May 11, 2009)

I don't see the exploratory part of the op report in your post, so it that's the entire report I'd just code the lipoma excision.


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