Orthopedic Coding Alert

The reports you receive aren't always as pristine as you want them to be, and this real-life report is no exception. Read through the documentation to determine the appropriate codes and the areas where you need more information.

Hint: Don't worry about choosing HCPCS codes. The facility would report the supplies, says Shelly Ghrist, CPC, assistant manager of Wolf Creek Medical Associates in Grove City, Pa.

Preoperative diagnosis: Unknown soft tissue mass, left foot

Postoperative diagnosis: Unknown soft tissue mass, left foot

Operation: Excision of subcutaneous soft tissue mass, left foot

Gross findings and procedure description:

Anesthesia: Local with IV sedation

Hemostasis: Pneumatic tourniquet at 250 mmHg x 18 minutes

Estimated blood loss: Less than 5 mL

Materials: Xeroform gauze and 3-0 Prolene

Post-op injections: 5 mL 0.5 percent Marcaine plain

Procedure: This patient was taken to the operating room and placed on the operating table in supine position. Following the introduction of intravenous sedation and regional local anesthesia, the left foot was prepped and draped in the usual sterile manner. At this time, two converging semi-elliptical incisions were created in the plantar aspect of this mass on the left foot and deepened down to the level of the subcutaneous tissue. The encompassing skin wedge and soft tissue mass were meticulously dissected free with blunt and sharp scissors. It was noted to go into the fat tissue. It was a hard fibrotic mass. The mass and skin were excised in toto.

We further explored the area. No other suspicious-appearing lesion was noted. The wound was flushed copiously. We then closed the wound. Post-op injection and Xeroform gauze were applied. A post-op dressing was applied.

Diagnosis: Foot mass, left, granuloma dermatitis with polarizable foreign bodies (possibly silica), excised. Subcutaneous fat is present at the base of the excision.

Received is an elliptical portion of tan tissue measuring 26 x 9 x 12 mm. A centrally placed ulcerated lesion measures 3 x 3 mm. No orientation identified. The surgical margins are inked. No masses identified grossly. Sectioned and totally submitted.

The op note offers the diagnosis: "Unknown soft tissue mass, left foot."

The surgical pathology report details another diagnosis: "Foot mass, left, granuloma dermatitis with polarizable foreign bodies (possibly silica)."

What to do: Choose your ICD-9 code based on the path report.

You should assign 709.4 (Foreign body granuloma of skin and subcutaneous tissue) for the diagnosis, Ghrist says.

Bottom line: You must have the pathology report, or you have no way of knowing what type of mass the surgeon removed, Ghrist says.

Pulling a CPT code from this report won't be simple. You need measurements to choose the appropriate code, and the op note didn't include the lesion size as it should have, Ghrist says. In this case, only the path report includes lesion size. And neither reports the margin measurements.

The provider has the "responsibility to measure the lesion with margins prior to excision of the lesion," says Yvonne P. Mayer, CPC, a senior coding analyst in Indianapolis.

Why it matters: According to CPT 2008, "Code selection is determined by measuring the greatest diameter of the apparent lesion plus the margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter). The margins refer to the most narrow margin required to adequately excise the lesion, based on the physician's judgment."

In other words: You should base your CPT code not just on lesion size but also on margin size.

What to do: Measure the lesion's greatest clinical diameter, plus the margins required to completely excise the lesion, says Shelley Bellm, CPC, physician relations and coding manager at Colorado Mountain Medical in Edwards.

To do this, measure the lesion's widest diameter point, then add double the width of the narrowest margin. See "3 Steps Steer You Clear of Excision Coding Snafus" on this page for more information.
Also, when selecting your CPT code, remember to use measurements that the provider takes before excising the lesion. Lesions shrink when the pathologist analyzes them, which means the 3 mm x 3 mm in the sample path report is probably smaller than the lesion's actual size.

If the surgeon can't provide the actual measurements, you may have to code this excision conservatively by using the 3-mm x 3-mm lesion measurement because you have no documentation of the narrowest required margin. A 3-mm diameter translates to 0.3 cm, which merits 11420 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less).

Cost: Code 11420 has 2.02 transitioned facility total relative value units, while the next-level code, 11421 (- excised diameter 0.6 to 1.0 cm), has 2.71. Multiply these RVUs by the conversion factor for the first half of 2008 (39.7924) and that means about $80 for 11420 and $108 for 11421, a difference of about $28.