# mandible lesion excision with excision and nitrogen in tumor cavity.



## hbair99 (Apr 19, 2017)

Hoping for a little clarification.  Provider does a benign lesion excision of mandible with bone graft and liquid nitrogen was placed in the tumor cavity, times 3 for less than 1 min each.  Prior auth for 21025 bone excision mandible, 41850 other destruction of lesion with out excision and 21215 for the bone graft.  I was thinking 21046 for excision of lesion and 21215 for bone graft, but nothing for the additional nitrogen since that cpt states no excision.  Any help is so appreciated!!!!!


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## JenniferB7 (Apr 19, 2017)

Do you have a copy of the operative report that you can share?   It is hard to determine coding for this type of situation without seeing the operative report.     It looks like you have an excision and a destruction of a lesion.  I can't tell if they are two separate lesions or if your surgery used two methods for the same lesion.

Remember:  Do not post any patient information (name, DOB, MRN, etc.) when sharing an operative report. 


Sincerely,

Jennifer M. Connell, CPC, CENTC, CPCO, CPPM, CPMA, CPC-P, CPB, CPC-I


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## hbair99 (Apr 19, 2017)

*Let me know what you think???*

Preoperative Diagnosis:
Cystic lesion/tumour right mandible in setting of previously excised
ameloblastoma
.
Postoperative Diagnosis:
same
.
Procedure Performed:
Right mandibular tumour excision
Liquid Nitrogen cryotherapy to right mandibular defect
Bone Graft (allograft) to right mandible
.

.
Detail:
Prior to the beginning of the procedure the team paused to verify the patient's
identity, as well as the procedure to be performed and the correct side/site.
All equipment required was ready and available. The patient was positioned
appropriately.
.
Anesthesia:
GETA.  No complications
 Local - 0.5% marcaine 1:200,000 epi, total 17 ml
.
.
Prep:
chlorhexidine
betadine paint
.
.
Operative Note:
The patient was taken to the OR supine, prepped and draped in the usual fashion
and preoperative antibiotics administered.  Local anaesthetic was administered
via buccal infiltration and inferior alveolar nerve block to the affected side.
An incision was made overlying the right mandibular external oblique ridge
within the mucosa using electrocautery.  Dissection was carried out in
subperiosteal fashion exposing the tumour.  The tumour expanded the buccal and
lingual aspect of the mandible, and cystic appearing lining was present through
fenestrations visualized on the lateral aspect of the mandible.  Using a
Kerrison forceps, the outer cortex of the mandible along the external oblique
ridge and anterolateral border of the ramus was removed to expose the tumour.
The tumour was excised using currettes with care to avoid
sectioning/traumatizing the left inferior alveolar nerve.  The lesion was
thoroughly curretted and freed from the right mandible.  The mandible remained
intact throughout.  Chlorhexidine 0.12% was then irrigated through the tumour
site.  A round carbide bur was used to smoothen the edges of the remaining bone
and site thoroughly irrigated.  After carefully isolating the surgical site
withtowels, guaze, sterile tongue depressors and retractors, liquid nitrogen was
placed within the tumour cavity on 3 successive occasions, left in place for 1
minute each time and vapours suctioned during use.  The mandible was once again
irrigated.  The mandible remained intact/not fractured.  Particulate bone
allograft was then placed into the tumour defect and the buccal fat pad was
dissected free on the right and secured overlying the bone graft with 3-0 vicryl
sutures.  The wound was closed with 3-0 vicryl sutures in horizontal mattress
fashion, and oversewn with 3-0 chromic gut in running fashion.  Hemostasis was
obtained.
.
.
All counts are correct.  Extubation is without complication
.
Findings: Enucleated right mandibular tumour, multiple mandibular fenestrations
identified, but no frank fracture of mandible identified.
.
Specimens:  Tumour from right mandible for final path.
.


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## JenniferB7 (Apr 19, 2017)

I agree with your coding selection of 21046 for excision of the lesion and 21215 for bone graft.  It looks like the liquid nitrogen was used for destruction on the same lesion, so you would only bill the excision code.  When multiple methods are used to excise/destroy a lesion, you can only bill one code. 

(I also sent you a private message with a note about editing your last post.)

Hope that helps!

Jennifer M. Connell, CPC, CENTC, CPCO, CPPM, CPMA, CPC-P, CPB, CPC-I


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## hbair99 (Apr 20, 2017)

*Thank you!!*

I appreciate the help!  Kudos to all the ENT and oral maxillofacial coders out there!!!!!  This specialty is new to me and I am learning!  Very amazing stuff these surgeons do!!


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