Neurosurgery Coding Alert

Question: I have an operative note for "removal of painful mass (lipoma) left sciatic notch." Other documentation states that "the 2.5 cm mass was taken directly from the dorsal aspect of the piriformis muscle." What code is best for this?

Vermont Subscriber

Answer: The correct code depends on the location, but the most likely choice from your description is 27047 (Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm). If the excision went to the next tissue layer, report 27048 (Excision, tumor, soft tissue of pelvis and hip area, subfascial [e.g., intramuscular]; less than 5 cm) instead.