General Surgery Coding Alert

Question: Our surgeon excised a very large lipoma located primarily in the upper back, but extending into the right shoulder area. Which anatomic site should I use for coding the service, or should I code a lipoma excision for each site?

Missouri Subscriber

Answer: You should not code two lipoma excisions for the example you give. When an excision spans anatomic sites described by different codes, report the code that identifies the site that encompasses the majority of the lesion.

For a lipoma located predominantly on the back, choose from the following codes:

• 21930 -- Excision, tumor, soft tissue of back or flank, subcutaneous; less than3 cm
• 21931 -- ... 3 cm or greater
• 21932 -- Excision, tumor, soft tissue of back or flank, subfascial (e.g.,intramuscular); less than 5 cm
• 21933 -- ... 5 cm or greater
• 21935 -- Radical resection of tumor (e.g., malignant neoplasm), soft tissue of back or flank; less than 5 cm
• 21936 -- ... 5 cm or greater.

Check out 22: If the surgeon documents that this is a particularly large lesion requiring additional procedural work, you might consider appending modifier 22 (Increased procedural services) to the appropriate code.

If you expect additional payment when using modifier 22, you'll need to document the increased complexity of the particular case.

CPT® specifically recommends that physicians document the reason for the additional effort, such as "increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required."

Although you can add modifier 22 based only on the description of the work in the body of the note, it is practically impossible to get additional pay if you don't quantify the extra effort on the claim form.