Orthopedic Coding Alert

This foot-mass report requires you to dig deep for both CPT and ICD-9 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. Analyze the Op Note 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. Surgical Pathology Report: 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. Identify Which Report Reveals ICD-9 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. See Whether You [...]