Wiki 10040 or Excision series?

[sweetbud33]

I have a provider who coded this as 10040. I'm thinking this is an Excision. Patient will return to have sutures removed. Input please? Thank you much!
Below I listed an excerpt of the procedure performed:

Sebaceous cyst

PROCEDURE:
" ... a straight incision was made on the surface skin and cyst dissected off in total. The cyst was punctured and drained cheesy material during the dissection. No adhesion noted between subcutaneous tissue and cyst wall. Pathology was deferred as there was no clinical suspicion of atypia. The subcutaneous space was closed with a single figure of 8 knot using 3-0 vicryl. Skin was approximated with 2 simple interrupted sutures using 4-0 ethilon. The area was cleansed with normal saline and dressed with a bandage."

 

[ellzeycoding]

10040 isn't appropiate.

First, if it was just cut open and drained, then...

10060 - Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

However, since the note indicates that the cyst was dissected and removed and documentation was noted regarding the subcutaneous tissue, you could use the excision codes. The one thing missing (and you only included a snippet of the note, so it may be there somewhere in the rest of the operative report is the size of the cyst (including any margins or extra tissue from the edges). You would need a size documented to be able to choose the appropriate excision code.

Also, be sure to check your carrier' policies for cyst coverage. See if the have a removal of benign lesions policy. Cysts are sometimes considered medically unnecessary unless other symptoms are documented.

 

[sweetbud33]

Thank you kindly for your prompt response. Yes, the rest of the note is documented as to size and location.