General Surgery Coding Alert

Question: We have an op report for excision of a “subcutaneous mass” of the back with intermediate repair, but it doesn’t state the size of the excision. The pathology report returned as “lipoma, 2.6 cm diameter.” How should we code this?

Ohio Subscriber

Answer: The best procedure code you can select is 21930 (Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm) based on the information you have.

Opportunity: Because tissue shrinks during processing, waiting to use the excision measurement from the pathology report instead of the time of surgery could mean that you missed the chance to report 21931 (… 3 cm or greater). The pay for 21931 is $486.29, compared to $377.19 for 21930 (Medicare Physician Fee Schedule facility amount, conversion factor 35.8887). Make sure your surgeons measure excisions in the OR and record the info in the op report for the best reimbursement.

You should code the diagnosis as D17.1 (Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk).