# Second opinion.... Back mass excision



## MMillercpc (Sep 16, 2009)

Procedure: The patient was brought to the operating room and placed in the
supine position. With appropriate monitoring, she was induced with general
anesthesia without complication. She was then turned on her side and the area
was painted with Betadine and draped in a sterile fashion. An elliptical incision
was made encompassing some of the hairs over the mass and then
electrocautery was used to dissect around the mass. The mass was excised and
sent in its entirety to pathology for evaluation. 3-0 Vicryl was used to
reapproximate the subcutaneous tissue and 4-0 Vicryl was used to
reapproximate the skin in a subcuticular manner. Steri-strips and a dry sterile
dressing were applied.

11400
12031 for double layer closure?? 

DX782.2


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## scronin (Sep 17, 2009)

From reading your note I am pointed in the direction of CPT code 21930 - Excision, tumor, soft tissue of back or flank. Using this code would account for the layered closure since it is specifically included in the code description.

I hope this helps.


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## Treetoad (Sep 17, 2009)

I would look to the pathology report for a diagnosis.  I guess my biggest issue with this OP note is that it doesn't state how deep the surgeon went.  I don't think there's enough information in this note to justify the excision of a soft tissue mass.


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## MMillercpc (Sep 17, 2009)

An elliptical incision
was made encompassing some of the hairs over the mass and then
electrocautery was used to dissect around the mass. The mass was excised and
sent in its entirety to pathology for evaluation. 3-0 Vicryl was used to
reapproximate the subcutaneous tissue and 4-0 Vicryl was used to
reapproximate the skin in a subcuticular manner. Steri-strips and a dry sterile

This is all Ive got... No path report either....


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## GJackson (Sep 17, 2009)

We never submit anything that is excised without the path report. I would hold until the path comes in.


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## Hopp (Sep 17, 2009)

*BacK Mass Excision*

I concur with awaiting for the pathology report .
Deborah, CPC


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## scronin (Sep 18, 2009)

While you are waiting for the path report, I would speak to the provider and ask how deep they went to get the specimen. However you know that they at least went into the subque tissue otherwise you wouldn't be able to do a layered closure.  But just for confirmation it wouldn't hurt to verify.


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