Dermatology Coding Alert

Question: For reporting lipoma removal, which codes are correct: the benign lesion codes or excision of soft tissue mass codes (in this particular case, the mass is on the left shoulder)?

California Subscriber

Answer: Either the codes for excision of benign lesion (11400-11471) or the codes for musculoskeletal soft tissue excision (in this case, for example, 23075, Excision, soft tissue tumor, shoulder area; subcutaneous) may be appropriate for removal of lipoma (fatty tumor). The code selection depends on the depth of the excision and the specificity of the dermatologist's documentation.

If the physician's incision does not go deeper than the fascia, you are correct to choose an appropriate code from CPT's "Integumentary System" section (11400-11471, Excision -- benign lesions).

For example, if the physician's documentation specifies "full-thickness excision of 2.5-cm lesion (with margins) from left shoulder with simple closure," you should choose 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 2.1 to 3.0 cm).

In this case, both the terms "full thickness" (that is, "through the dermis") and "simple closure" should tip you off that the required incision was not very deep.

If the incision goes deeper than the fascia, the lipoma removal is not just superficial, and you should look to the musculoskeletal codes because they would be more appropriate. The physician's documentation must be explicit to support using these codes and should specifically note the incision depth ("past the fascia").

In the above question, if the physician's documentation notes a subcutaneous tumor with incision depth to at least the fascia, you may report 23075. For even deeper incisions (subfascial or intramuscular), you may choose 23076 (... deep, subfascial, or intramuscular).

In these cases, the size of the lipoma or the excision does not matter, as it does when reporting the integu-mentary codes. And you may not report the musculoskeletal codes because a lipoma reaches a certain size (for instance, more than 5 cm). Only the depth of the incision, not the size of the tumor, matters.