Wiki 11403 vs 21555

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codedog

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I think this is 21555, office says its11403. the reason why I say its 21555 because its a lipoma,and he stated that the incsion was deepened down through sub tissues,
does anyone agree with me/,if not why /


POSTOPERATIVE DIAGNOSIS: Lipoma posterior neck.
OPERATION: Excision of lipoma.
After adequate premedication, the patient was taken to the operating room and placed on the operating table in the supine position. General anesthesia administrated and turned in the prone position and neck was prepped and draped in a sterile fashion. Transverse incision was made overlying the neck, deepened down through the subcutaneous tissue. The capsule was then easily identified. The lipoma enucleated. Minimal bleeding ensued. The wound was closed with 3-0 Vicryl on the deep tissues, subcuticular nylon on the skin. Blood loss was minimal. The patient tolerated the procedure and was taken to Recovery in stable condition.
 
path report just says received amass of firm yellow tan and firm rbbery glistening tissue eith dimemsions of 6x 2.6x 1.5 cm . On sectiong the specimen is rubbery, glistening and yellow.,

microscopic description -sections reveal benigh adipose tissue. dx - posterior neck- lipoma
 
yeah, but i dont see size in op report, i thoughy if no sizei in s dictation then you have to go by smallest size ?
 
No!!!!!! If no size at all you go by the smallest.... You can use the path size even though it is smaller because of shrinking in the formalin. That is why its important to try to get the doc to dictate it. But if path does not have it then you have nothing to go by......:)

Also I do EVERYTHING in my power to get the surgeon to dictate the size. the path is the last resort!!!!!
 
Last edited:
04/10/2011, 07:11:45 PM Margie S Vaught, CPC, PCE, CCS-P, MCS-P, ACS-OR, CPC-H
Per CPT it does not appear to be the most appropriate - but if it is all you have the payer/carrier may allow.

August 2000 CPT Assistant: "To properly code an excision of a lesion, the physician must document the SIZE and location of the lesion. The SIZE of a LESION is measured by its clinical diameter for a circular or elliptical lesion. The diameter is the length of a straight line segment that passes through the center of a figure, especially of a circle or sphere, and terminates at the periphery. If the LESION is asymmetrical or irregular, the maximum width is used to measure the lesion. The physician should make an accurate measurement of the LESION at the time of the excision, and the SIZE of the LESION should be documented in the operative report. A PATHOLOGY report is less likely to contain an accurate measurement due to the shrinkage or fragmentation of the specimen. When coding the removal of a lesion, do not report the SIZE of the surgical defect created or the affected area."

Fall 1995 CPT Assistant: "Since a physician can make an accurate measurement of the LESION at the time of the excision, the SIZE of the LESION should be documented in the operative report. A PATHOLOGY report is likely to contain a less accurate measurement, due to the shrinking of the specimen or to the fact that the specimen may be fragmented. When coding the removal of a lesion, do not report the SIZE of the surgical defect created or the affected area."

taken from codecorrect
 
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