Orthopedic Coding Alert

Determine the location, depth, and size to select the right code.

When reporting lipoma excisions, don't automatically code these services using tumor codes as a lipoma is a benign lesion consisting of fatty tissue.

For example, if your surgeon excises a 3 cm lipoma in the sacral region, you will be wrong if you report 49215 (Excision of presacral or sacrococcygeal tumor). This code is typically for tumors that lie at the base of the spine; these do not usually arise from the fatty tissue.

"Reporting 49215 would be a misrepresentation of the work value of the service to report removal of a subcutaneous lipoma," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Auditing and Coding, senior orthopedic coder & auditor, The Coding Network, Washington. "Code 49125 appears to be a more extensive procedure including resection of the presacral or sacroccygeal tumor," says Elizabeth Kenney, CPC-A, Department of Orthopaedics, University of Maryland Faculty Practices, Maryland.

Confirm Size and Depth for Lipoma

To accurately code a lipoma excision in the sacral region, you'll need to confirm the confines of the lipoma. If the lipoma is a full-thickness dermal mass in the sacral region, then you would choose 11400 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 0.5 cm or less) - 11404 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 3.1 to 4.0 cm), depending upon the size of the lipoma. Remember, you select the codes for benign lesions as a lipoma usually remains in its confines and does not spread. "A lipoma is by definition, benign and rarely, if ever, becomes malignant," says Bill Mallon, MD, medical director, Triangle Orthopedic Associates, Durham, N.C.

If the same lipoma in the sacral region is intramuscular, then you will report code 21932 (Excision, tumor, soft tissue of back or flank, subfascial [e.g., intramuscular]; less than 5 cm) or 21933 (Excision, tumor, soft tissue of back or flank, subfascial [e.g., intramuscular]; 5 cm or greater), depending upon the tumor is less than 5 cm or greater than 5 cm in size.

On the other hand: If your surgeon documents that the lipoma is just below the skin, you would report 21930 (Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm) or 21931 (Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater), depending upon the size of the tumor, i.e. less than or greater than 3 cm in size. "When your surgeon excises a 3 cm subcutaneous lipoma, CPT® code 21931 is the best choice. This is a benign neoplasm and is subcutaneous in nature," says Stumpf. "Codes 21930 and 21931 describe an excision of a tumor in the (subcutaneous) soft tissue and make an appropriate choice for lipoma. A lipoma is simply a benign tumor that contains fat cells," says Kenney.

You will also make the difference in sacral tumor removal and lipoma excision by confirming the approach that your surgeon adopted. "By description, a presacral tumor is removed through an anterior approach. The secondary description for this service is for coccygectomy for approach to remove a presacral tumor," says Stumpf. "The musculoskeletal system service described by CPT® codes 21930 and 21931 is more representative of the work value of a subcutaneous lipoma excision and would more appropriately represent the service."

Get the RVU scoop: There is also a difference in RVUs in the 49215 and 21930/21931. "CPT® code 49215 has a value of 64.30 RVUs. CPT® code 21930 has an RVU value of 10.76. CPT® code 21931 has an RVU value of 13.89," says Stumpf. "The high RVU value for 49215 reimburses the surgeon for a very complex procedure to access a presacral tumor via either deep abdominal approach, or resection of the coccyx to access the tumor via a posterior approach."

ICD Code: For lipomas, you will confirm the site to select the right ICD-9 code from 214.0 (Lipoma of skin and subcutaneous tissue of face), 214.1 (Lipoma of other skin and subcutaneous tissue), 214.2 (Lipoma of intrathoracic organs), 214.3 (Lipoma of intra-abdominal organs), 214.4 (Lipoma of spermatic cord), 214.8 (Lipoma of other specified sites), 214.9 (Lipoma unspecified site). "Lipomas have their own code series and the codes are site specific," says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.