General Surgery 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 in 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), depending on the depth of the excision and the specificity of the surgeons documentation.
 
If the surgeons incision does not go deeper than the fascia, you are correct to choose an appropriate code from CPTs Integumentary System section (11400-11471). For example, if the surgeons 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 surgeons 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 physician 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 integumentary 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 incision, not the size of the tumor, matters.   Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb.