Orthopedic Coding Alert

Question: Below is a part of the operative note recorded by our surgeon.

"The osteotome was used to separate the tumor from the underlying clavicle and the remaining soft tissue attachments were incised.  The mass was removed from the operative field.  It measured 12.5x12x3.5 cm.  There was noted to be heaped up reactive bone distally. This was osteotomized and sent as a separate section.  It was also curetted and burred down with the Midas Rex bur until there was normal-appearing reactive bone...."

Can we choose code 23140 (Excision or curettage of bone cyst or benign tumor of clavicle or scapula) or 23480 (Osteotomy, clavicle, with or without internal fixation) for this procedure? We are also reporting code 23200 (Radical resection of tumor; clavicle) for benign radical resection of tumor down to muscle. Please confirm.

New Jersey Subscriber

Answer: The most appropriate code in this scenario will be 23140. You will not report this case as radical resection as clean tumor margins are needed in a radical resection, and to attain that in this case, a part of the clavicle needs removal. Since we do not see any documentation for the removal of clavicle, you would not report radical resection.