Anesthesia Coding Alert

Question: Our physician provided anesthesia while the surgeon removed a lipoma on the patient's posterior shoulder. Is the shoulder considered part of the extremity regardless of anterior or posterior? Or is the posterior shoulder part of the posterior trunk?

Maine Subscriber

Answer: Medical definitions usually associate "trunk" with the torso -- the main part of the body other than the head and extremities. When you look at divisions such as the Rule of Nines for burn coding, they also label the posterior shoulder area as the trunk. Extremities are usually the arms, legs, and head.

That being said, the correct code for your case depends on exactly where the lipoma was located. If by "posterior shoulder" you mean "upper back," the correct anesthesia code would be 00300 (Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified). If the lipoma was actually more in the area of posterior upper arm (an extremity), you would use 00400 (Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified).