# What's  wrong with buttock mass ?



## codedog (Feb 23, 2010)

Looking in the index in cpt code book there isnt really any specfic  code for an excisional  biopsy of buttock mass.

Here is the operative report :Excisional  biopsy of buttock mass, presumed  epidermal  inclusion cyst

The patient was bought into the operating room and placed on the operating table in  lateral decubitus  position. The right buttock was prepped and draped in a sterile fashion. Then 9 cc of  1% lidocaine with epinephrine was injected for local  anesthesia. An  elliptical  incision was made over the mass to excise it with grossly negative margins. There was no sign of infection. The wound was irrigated with normal  saline. The subcutaneous tissue was closed with interrupted  3-o Vicryl, and 4-o nylon  horizontal  mattress sutures were  used to close the skin . A sterile  dressings  was applied 

Now , its an epidermal cyst which i would want to code 1140x, but doc did not state the size of  cyst , or do i code   it from musculoskeltal system ?
any suggestions? please reply


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## Walker22 (Feb 23, 2010)

I agree that 1140x is the right code set to use.. but you don't have enough documentation to choose a proper code. I think your physician needs some training in how to document this procedure properly. I don't see how there is any code from the musculoskelatal system that would apply.

Maybe you can get your doctor to make an addendum to the op note stating the size of the lesion...


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## codedog (Feb 23, 2010)

Thanks walker 22,


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