Dermatology Coding Alert

Reader Question:

Mark Depth of Lipoma Before Choosing Code

Question: How would I code for the removal of a mobile lipoma from the right flank over the ribs? The encounter note states the physician performed the procedure “using good local block excised through a 12 cm incision in an encapsulated 7x6.5 cm lipoma.”

Illinois Subscriber

Answer: It depends on the depth of the lipoma the physician removed. If the lipoma was subcutaneous, you should report 21931 (Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater).

If notes indicate that the lipoma was subfascial or intramuscular, however, 21933 (Excision, tumor, soft tissue of back or flank, subfascial [e.g., intramuscular]; 5 cm or greater) is probably your best bet.

To be safe, check with the provider who performed the service if you have any doubt as to the depth of the lipoma.  

Which Codify by AAPC tool is right for you?

Call 844-334-2816 to speak with a Codify by AAPC specialist now.