# Leg mass -enough documentation



## codedog (Jan 22, 2010)

Just want some other views to see if doctor is lacking documentation


Postoperative diagnosis : Right  leg  mass 

Operation : Excisional biopsy of right leg mass 

Anesthesia :  MAC

 Clinical  HISTORY: Patient has a mass on right  medial distal leg in need for biopsy

Procedure? The patient was bought into the operating room, placed on the operating table in supine position. The right distal leg was prepped in a sterile fashion. 10 CC OF 1 % lidocaine with epinephrine were injected for local esthesia> A  longitudinal elliptical  incision was made to excise the mass with grossly negative margins. Electrocautery was used to dissect through the subcutaneous tissues. Hemostasis was used to achieved with electrocautery. The wound was irrigated with normal saline. The skin was closed with a cobination of 3-0  nylon  horizontal  mattress ans simple sutures. The patient tolerated the procedure well.

Would cpt code 27613 be the code or 27618 or do i go into integumentary system, and if so, lack of documentation ?Someone wants told  me if its excisional that means they excise the whole mass/tumor/ cyst,so biopsy made not fit ? help


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## bench (Jan 22, 2010)

Your op-report is missing the measurement of the excision. You can code this under the excision of tumor soft tissue as the op-report stated that the tumor was excised with a negative margin. Your code would be right 27618-RT if the excision size is less than 3cm. Hope this helps.


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## codedog (Jan 22, 2010)

so it it states negative margins i code into 2000 series /


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