Urology Coding Alert

Question: My urologist made an elliptical excision, in total length of 5 cm, around the sinus tract and cystic lesion. In dissecting through the subcutaneous tissues, my urologist entered into an abscess pocket, about 1 cm deep. Small amount of mildly purulent fluid was evacuated, and then the abscess tract was entirely excised. The patient did have a sinus tract extending from caudal to cranial, medial to lateral. This was completely excised. It did not enter the tunica vaginalis. At the conclusion, the entire sinus tract and scrotal cyst appeared to be completely evacuated from this area. Hemostasis was achieved. The wound was irrigated and reapproximated with a deep layer of running 3-0 Vicryl suture. The skin was reapproximated with interrupted 3-0 Monocryl suture. Should I report code 13160 or 11426?

AAPC Forum Subscriber

Answer: You should report codes 11426 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm) and 10061 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple) with modifier XU (Unusual non-overlapping service…) appended.

Don’t miss: When it comes to the excision code (11426), you must always check the diameter of the lesion, as well as the margins excised, to report the appropriate code. Code for the size of the lesion and two times the smallest margin also excised to arrive at the correct code size. For example, if the lesion is one cm and your urologist removes the lesion with a 1 cm margin (1cm + 2 x 1cm =3 cm), you should report a 3cm lesion removed — 11423 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm) instead.

When a wound requires layered closure of one or more layers as well as a simple skin closure, you should code this as an intermediate repair with the addition of 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less) to 12007 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm) to the 11420 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less) to 11426 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm) codes. Therefore, for a layered closure, choose the appropriately sized code from the 11420-11426 series, in addition to the correct sized code from the 12001-12007 series. You should code two codes to indicate a layered closure.

For the above case, you should report codes 11426 and 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm).

You should report code 10061 if your urologist performed incision and drainage (I&D) of a complex abscess or multiple abscesses. A complicated I&D takes more time than usual and may involve multiple incisions, drain placements, extensive packing, and subsequent secondary wound closure.