Question 26111 VS 26160 Help please

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dsibley67

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I am leaning more toward CPT code 26111 but the statement that he makes "We released it from the ulnar aspect of the flexor sheath as well." has me thinking that maybe it could be coded as CPT 26160. Below is the op note. Any help in determining the correct code would be appreciated.
POSTOPERATIVE DIAGNOSIS: Right small finger mass.
PROCEDURES PERFORMED: Exploration and removal with right small finger mass
The patient was seen preoperatively, site was marked and
verified. Time-out was taken at the beginning of the procedure. The arm was exsanguinated. The
tourniquet was inflated. A zigzag incision was made at the base of the small finger overlying the large
mass with approximately 3 cm in circumference, soft and mobile. We developed the flap proximally,
identified the ulnar neurovascular bundle and began to trace this into the mass. The nerve and vessel
internally involve with the mass. We likewise identified the neurovascular bundle on the distal extent and
then slowly carefully dissected out the intervening segment until we able to free up the neurovascular
bundle from the mass. The mass was solid and scarred in. We released it from the ulnar aspect of the
flexor sheath as well. Flexor sheath was unharmed. There was some ash like debris that was debrided
from the area as well. Once the mass was excised, it was sent off for pathology. We then irrigated the
wound thoroughly. The tourniquet was released. No significant bleeding was noted and the patient
remained intact. The nerve was intact as well. At this point, the wounds were closed with 4-0 Prolene.
He was placed in a soft bulky dressing and tolerated the procedure well
 
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If it was adherent to deep structures (flexor tendon sheath), it would qualify as a "deep mass", though it would help if your surgeon dictated more clearly the depth of the dissection, and you should let him/her know that there is a substantial difference in reimbursement between the two. He/she makes it questionable.

This can be coded either 26113 or 26111.
I would code 26113.
26160 is for a ganglion, which is not how this is described.
 
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You will code this procedure based on the diagnosis of the mass, and where it was removed from. I would wait for the pathology report to come back with an accurate diagnosis, and that will help direct you to the most appropriate CPT code.
 
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adunlap23 said:
You will code this procedure based on the diagnosis of the mass, and where it was removed from. I would wait for the pathology report to come back with an accurate diagnosis, and that will help direct you to the most appropriate CPT code.
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Would disagree with that.

Your procedural coding is based on the work performed during the surgery. We like diagnosis codes and CPT codes to be corresponding, especially for the purposes of preauthorization, but that is not always the case, particularly with tumor excision. We are planning surgery based on a presumptive preoperative diagnosis, but we often find different things when we get in there. Unless you do a frozen section intraoperatively and that leads you to perform more surgery at the time, the final pathological diagnosis should be irrelevant to the procedural coding of the case.

A few examples:
1) If you did a marginal mass excision with a presumptive diagnosis of a benign tumor, and you send it to pathology and it comes back as a sarcoma, you don't magically get to use a sarcoma code in your billing, as that presumes a radical excision, which was not performed.

2) If you send what appears to be a solid mass to pathology, and it comes back as a calcified ganglion, you don't subsequently downcode to a ganglion excision.

3) if you go into a finger expecting a retinacular cyst (ganglion) and you find a giant cell tumor, you code that as a mass excision, not a ganglion excision, as the work is different.

4) You perform a bony debridement ("craterization") for what is assumed to be osteomyelitis. Pathology comes back without evidence for osteomyelitis. That does not change the work you did, based on a suspected or presumptive diagnosis, and it does not compromise your ability to use the appropriate code for the work that you did.

That's not to say there aren't codes where diagnosis or intent matters, for example radial head replacement for arthritis vs radial head replacement for fracture, or the difference between I&D of a postoperative wound infection vs a traumatic wound. But for tumors, it is the nature of the work that determines the code.
N
 
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I understand your reasoning for choosing a CPT code based on the work performed, but in my personal experience, most payors will deny a CPT code if the dx does not match the procedure. It's also in my experience that billing a general code such as R22.3: Localized swelling, mass, and lump, upper limb, will result in a denial. So, you almost have to code by the path results.

I understand billing rules will vary by payor. I'm am curious to hear how others approach this type of coding situation.
 
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adunlap23 said:
I understand your reasoning for choosing a CPT code based on the work performed, but in my personal experience, most payors will deny a CPT code if the dx does not match the procedure. It's also in my experience that billing a general code such as R22.3: Localized swelling, mass, and lump, upper limb, will result in a denial. So, you almost have to code by the path results.

I understand billing rules will vary by payor. I'm am curious to hear how others approach this type of coding situation.
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Ashley - I totally agree here, but we almost never use Symptom ICD's, and would definitely agree with you to stay away from R-codes.

I looked back through my last year's worth of mass excisions and confirmed that we always used D-codes (D21.1x, D21.9, D48.9, etc) for benign or unspecified neoplasm, and that is my preoperative diagnosis and not related to the pathological findings. You don't need anything more specific than that to avoid denials, but "lump" or "mass" gets crosswalked into the R-codes by many EMR and coding systems, and that is definitely a recipe for denial.

Cheers,
N.
 
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