Wiki 21555

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Would cpt code 21555 be the right code for this case?

Preoperative Diagnosis: Left chest mass.

Postoperative Diagnosis: Left chest mass.

Operation: Excisional biopsy of left chest mass.

Procedure in Detail:

The patient was brought into the operating room, and placed on the operating table in supine position. Left chest was prepped and draped in a sterile fasgion. 10 cc of 1% lidocaine with epinephrine was injected with local anesthesia. An elliptical incision was made directly over the mass. Electrocautery was used to dissect to the subcutaneous tissue to excise mass with grossly negative margins. There was no sign of infection.Hemostasis was achieved with electrocautery. The wound was irrigated with normal saline. The subcutaneous tissue was closed with interrupted 4-0 Vicryl and 4-0 nylon horizontal mattress suture was used to close the skin. The edges of the skin came together easily without tension. A sterile dressing was applied. The patient tolerated the procedure well.

Gross Examination:

Recieved is an elliptical fragment of skin and underlying fat measuring 2.1 x 1.5 x 0.7 cm; bisected and entirely submitted in one cassette.

Pathology came back with a diagnosis of: L Chest Mass - Ruptured epidermal inclusion cyst.

Should I code it as 21555 because he went subcutaneous or should I code it in integumary system because it came back as a ruptured epidermal inclusion cyst?

Thanks.
 
I would go with the 21555 since that is what was actually done during the procedure.....

I know we wait for path's here before we code procedures so I understand why you would want a second opinion but my opinion is since that was what was done, you code for it.
 
the reason why i asked the doctor office does their billing from an outside source and they coded as 11400 and dx as 239.2 . this is where i get confused. I thought if they had a code in 2000o section that has subcutanous use it . yes path did come back as a cyst but he went subcutaneous , a little confused , can someone tell me WHO IS WRONG OR RIGHT ?
 
I would Not code this as 21555, I would go with integ section 114 w/ an intermediate closure 120 section.
 
I say you are correct with 21555 and I would use the dx of 215.4 (under neoplasm table, subcutaneous tissue, then to connective tissue, chest wall). Hope this helps.
 
I think what is confusing here is the trem chest mass, however I would code the 114 code as well given the procedure description. The definition of excision is full thickness removal, full thickness must be through the dermis and into the subcutaneous tissue. This is what I see documented, with the dx of cyst.
To Heather: You may not use the 214.x code for the neoplasm because that is not confirmed by pathology. At no point did the physician or the pathologist render a dx of a neoplasm benign or malignant or uncertain, therefore as stated you as a coder cannot give the patient a dx they do not have.
 
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