Orthopedic Coding Alert

Reader Questions:

Report 49215 for Sacral Excision of Tumor

Question: Our physician performed a sacral tumor excision, which required him to remove the coccyx to reach the tumor. I am planning to report an unlisted-procedure code for this, but what "compare" code should I use for this procedure? We are considering comparing it to 27080 (Coccygectomy, primary) but aren't sure if that's correct.

Delaware Subscriber

Answer: You may not need to report an unlisted-procedure code for this service. CPT includes a code for sacral tumor excisions, but you won't find it in the musculoskeletal section.

You should report 49215 (Excision of presacral or sacrococcygeal tumor) if the physician removed a sacral tumor. You shouldn't report a separate code for the coccyx removal because that work is included in 49215.

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