# Sos! Please help



## Kevinph84 (Jun 4, 2013)

Hello Everyone,

This case was booked as an excision of an inclusion cyst. However, to me it appears to be a foreign body removal (including its reaction). I called the surgeon's office whom said they chose CPT 28090 (Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot) with a diagnosis of 706.2. However! I feel CPT 20525 (Removal of foreign body in muscle or tendon sheath; deep or complicated) or CPT 10121 (Incision and removal of foreign body, subcutaneous tissues; complicated) would be more appropriate. 

The final pathology report indictated the specimen was Skin and Subcutaneous fibrous tissue with focal ulceration, acute inflammation, and apparent abscess formation. I posted pertinent excerpts from the operative report below. What do you all think? Thank you for your help. 

PREOPERATIVE DIAGNOSIS:  PAINFUL INCLUSION CYST, POSTERIOR RIGHT ANKLE.

POSTOPERATIVE DIAGNOSIS:	SAME AS ABOVE.

PROCEDURES:	EXCISION AND REMOVAL OF INCLUSION CYST, POSTERIOR       RIGHT ANKLE.

ANESTHESIA:	IV SEDATION WITH LOCAL BLOCK CONSISTING OF 1:1 MIXTURE OF 1% LIDOCAINE PLAIN AND 0.25% MARCAINE PLAIN, 20 ML.

PATHOLOGY:	SOFT TISSUE MASS/INCLUSION CYST MEASURING APPROXIMATELY 0.8 X 1.0 AND ALSO WOUND CULTURE TAKEN OF DRAINAGE.

HEMOSTASIS:	PNEUMATIC ANKLE TOURNIQUET AT 250 MMHG, RIGHT ANKLE.

MATERIALS:	4-0 VICRYL, 4-0 NYLON.

COMPLICATIONS:	NONE.

INDICATIONS FOR PROCEDURE:  This is a 54-year-old patient who is well known to me who underwent surgery for excision of retrocalcaneal spur and repair of significantly torn Achilles tendon approximately four to five months ago.  The patient did very well following the surgery.  However, he developed a small inclusion cyst at the very proximal portion of the incision.  I have been treating the area conservatively and has done very well but it continues to persist.  

PROCEDURE IN DETAIL:  Under mild sedation, the patient was brought to the operating room placed on the operating room table in a partially side position for access to the posterior right leg.  Local anesthesia was performed following IV sedation and the right foot and ankle were then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was utilized to exsanguinate the area and the pneumatic ankle tourniquet was inflated.

Attention was then directed to the posterior aspect of the patient's right ankle in the area of the cyst.  At this time, a semi-elliptical incision was created around the area and was deepened through the subcutaneous tissue utilizing both sharp and blunt dissection with care being taken to identify and retract any vital neurovascular structures in the area which were either retracted, Bovied, or ligated as deemed necessary.  At this time, the ellipse of skin was removed and also incorporated part of the cyst with it.  There was some mild drainage noted from the area which was cultured and sent to pathology.  At this time, the area was evaluated and there was noted to be some subcutaneous cyst formation which was debrided both sharp and bluntly and resected and removed from the operative field.  There was noted to be a small loose piece of Ethibond FiberWire suture which was most likely causing the inclusion cyst which was removed from the wound.  The wound was then flushed with copious amounts of sterile normal saline.  The area was debrided off abundant scar tissue formation to aid in the closure.  At this time, deep tissues were approximated with one to two Vicryl stitches.  At this time, the skin was reapproximated and coapted utilizing 4-0 nylon and in the horizontal mattress suture technique.  The incision site was then dressed utilizing Betadine-soaked Adaptic, covered with sterile compressive dressing using 4x4 and Kling.  The pneumatic ankle tourniquet was released and prompt hyperemic response was noted to all digits of the right foot.  An Ace wrap was then applied distal to proximal on the patient's right foot and ankle. The patient tolerated the procedure and anesthesia well without any complications


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## pannpoo (Jan 12, 2015)

*Inclusion cyst excision*

First off, I would throw out any code that mentions tendon sheath as I don't see mention of a tendon sheath in the operative note.  Also, I try to avoid the 101XX codes as I feel these are usually, frankly, poor-paying, and prefer to use a more region-specific code if possible; such as, 27618 with the f.b. being incidental.  Note doctor's dictated "PROCEDURES" and "PATHOLOGY" which note that it was a mass.


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