General Surgery Coding Alert

Question: What is the appropriate code for a procedure that the surgeon describes as "wide excision of the skin, subcutaneous tissues and some fascia of abdominal wall measuring 20 cm x 10 cm."?

Tennessee Subscriber

Answer: The procedure description you've given doesn't provide enough information to assign a definitive code. You'll need to look for other clues in the documentation, such as whether this is a reexcision of a malignant lesion or an excision/resection of a soft tissue tumor. That said, look at the following coding possibilities:

Option 1: For a soft tissue tumor you might use 22903 (Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm. or greater) or 22905 (Radical resection of tumor [e.g., malignant neoplasm], soft tissue of abdominal wall; 5 cm or greater), depending on the diagnosis.

Option 2: For a wide reexcision of a malignant lesion or melanoma, you should report 11606 (Excision, malignant lesion including margins, trunk, arms or legs; excised diameter over 4.0 cm). If the site requires intermediate or complex closure, you can additionally report a code from 12031-12057 (Repair, intermediate ...) or 13100-13160 (Repair, complex ...)

Reader Questions and You Be the Coder were prepared with the assistance of Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.