Urology Coding Alert

Question: According to the medical documentation, after verbal informed consent was obtained, the patient was placed supine, washed with Betadine, and my urologist utilized 3.0 mL of 2% lidocaine plain injected around the inferior base of the suprapubic tube region. He then used electrocauterization to excise the granulation tissue. This was carefully cauterized, and he reduced the region down to a contoured site. What code should I report for this procedure?

AAPC Forum Member

Answer: To appropriately report this case, you need to know the size of the specimen your urologist removed. You would then look to codes 11400 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less) to 11406 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm), depending upon the lesion size removed. You should consult with your surgeon concerning the size of the tissue removed.