Dermatology Coding Alert

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

Washington Subscriber

Answer: You can report either the codes for benign lesion excision (11400-11471) or the codes for musculoskeletal soft tissue excision (in this case, for example, 23075, Excision, soft tissue tumor, shoulder area; subcutaneous) for removal of lipoma (fatty tumor).

Don't forget: Your code choice depends on the depth of the excision and the specificity of the dermatologist's documentation.

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

Example: If the dermatologist's documentation specifies "Full-thickness excision of 2.5-cm lesion (with margins) from left shoulder with simple closure," the appropriate code choice is 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 term "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 the musculoskeletal codes are more appropriate. The dermatologist's documentation must be explicit to support the use of these codes and should specifically note the depth of the incision ("past the fascia").

In the above question, if the dermatologist'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 (Excision, soft tissue tumor, shoulder area; deep, subfascial, or intramuscular).

In these cases, you should not consider the size of the lipoma or the excision, as you would when reporting the integumentary codes.

Red flag: You may not report the musculoskeletal codes because a lipoma reaches a certain size (for instance, more than 5 cm).

In cases related to the musculoskeletal codes, you should only look to the depth of the incision, not the size of the tumor.