Urology Coding Alert
Perineal Mass
Question: How should we code for removing a large perineal mass? It is not attached to the urethra, but it is deep. Should we wait for the pathology report to come back before choosing the code and filing the claim?
New Hampshire Subscriber
If the mass is benign and subcutaneous CPT code 11426 (excision benign lesion except skin tag [unless listed elsewhere] scalp neck hands feet genitalia; lesion diameter over 4.0 cm). If malignant CPT code 11626 (excision malignant lesion scalp neck hands feet genitalia; lesion diameter over 4.0 cm).
It is recommended that you not wait for the lab report. Code the removal as either malignant or benign based on the way you treat the mass when you perform the procedure. For example if you view it as possibly malignant and remove all surrounding tissue as a result code it as an excision of a malignant lesion. If you treat it as benign without worrying about the margins code it as a benign lesion.
The August 2000 CPT Assistant says to select the CPT code based on ""the manner in which the lesion is excised rather than the final pathological diagnosis."" The rational for this is that the code ""should reflect the knowledge skill time and effort that the physician invests in the excision of the lesion."" This means deciding whether the lesion is ambiguous but low-suspicion (use benign code 11426) or ambiguous but moderate-to-high suspicion (use malignant code 11626).
If the closure is complicated use an add-on complex repair code (13132 repair complex forehead cheeks chin mouth neck axillae genitalia hands and/or feet; 2.6 cm to 7.5 cm) in addition to the excision code. If the repair exceeds 7.5 cm CPT 13133 (... each additional 5 cm or less [list separately in addition to code for primary procedure]) as an add-on to 13132 as well as the excision code.
If the mass is very large append modifier -22 (unusual procedural services) to indicate the extra work performed.
Alternatively in a female code 57135 (excision of vaginal cyst or tumor). For a male try the unlisted-procedure code 55899 (unlisted procedure male genital system). Both of these codes allow you to opt out of deciding whether the mass is benign or malignant prior to filing the claim.
If you discover the mass is a urethral diverticulum code 53230 (excision of urethral diverticulum [separate procedure]; female) 53235 (... male) 53240 (marsupialization of urethral diverticulum male or female) or 53250 (excision of bulbourethral gland [Cowper's gland]).
Although this procedure sounds more like a muscle biopsy than a subcutaneous biopsy there are no muscle codes for the perineum. Do not use 27041 (biopsy soft tissue of pelvis and hip area; deep subfascial or intramuscular) 27047 (excision tumor pelvis and hip area; subcutaneous tissue) or 27048 (... deep subfascial intramuscular).
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