General Surgery Coding Alert

Question: Our surgeon excised a 3.4 cm lipoma in the sacral region. Should I choose a code from the benign (114xx) or malignant (116xx) lesion excision codes? Or should we report 49215?

Kansas Subscriber

Answer: None of the codes you mentioned would be appropriate for a sacral lipoma excision. Instead, you should report a soft tissue tumor code based on the location, depth, and size of the lipoma.

Here's why: Lipomas are benign fatty tumors that generally occur blow the skin. You should not choose a code from the integumentary system to describe a lipoma excision.

If the surgeon documents a tumor excision that is only a full-thickness dermal mass from the sacral region, then you would choose 11404 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm) or 11604 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm.).

Nor should you report 49215 (Excision of presacral or sacrococcygeal tumor). That code describes tumors of the base of the spine or between the base of the spine and the rectum that typically do not arise from fatty tissue.

Look to soft tissue codes: Instead, you should choose the appropriate code from the musculoskeletal section. For instance, if this lipoma is intramuscular, you would report 21932 (Excision, tumor, soft tissue of back or flank, subfascial [e.g., intramuscular]; less than 5 cm.) On the other hand, if the lipoma is just below the skin, you would report 21931 (Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater).