General Surgery Coding Alert

Question: The op note states that the surgeon removed a “5 x 5.5 cm mobile lipoma” from the right flank over the ribs, excised through a 13 cm incision. How should I code this?

Codify Subscriber

Answer: The lipoma excision code you choose will depend on the depth of the lipoma, which you don’t indicate.

If the lipoma was subcutaneous, you would report 21931 (Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater).

If notes indicate that the lipoma was subfascial or intramuscular, however, a better code choice would be 21933 (Excision, tumor, soft tissue of back or flank, subfascial [e.g., intramuscular]; 5 cm or greater).

Look back at the op note and see if the surgeon indicates the depth of the lipoma, or contact the surgeon for the information, if necessary.