Axillary mass, excision
sep5078, Have you had any reply to your question submitted tot he AHA Coding Clinic? We also have a scenario related to this matter. After final pathology, the below example ended up being fibroadenoma.
We have considered code 21552 (Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater)
We have also considered code 24071 (Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater). The coder used 11406. Dx D36.7.
One of our prior rationales for using the 21555 or 21552 is because the Dx crosscode for neoplasm thorax included axilla in it. Official guidance for this would be greatly appreciated.
"OPERATIVE FINDINGS: Large, approximately 10-12 cm axillary mass, unclear
on gross examination as to the diagnosis. Frozen section is most
consistent with a benign cyst adenoma with benign fibroglandular
proliferation.
...Skin incision was made in an elliptical fashion
incorporating a skin tag that he also desired to have removed. The skin
tag and some overlying skin was removed exposing underlying mass. The mass
was circumferentially dissected free. The mass had a strange appearance
and multiple cystic portions to it and purplish appearance. It did not
appear to be a lipoma. It was unclear as to what the diagnosis was just
based on gross examination. So I did go ahead and send this for frozen
section. Frozen section appeared to be benign. It was most consistent with
a fibroglandular proliferation. The mass had been removed in its entirety.
Hemostasis was achieved using electrocautery. Incision was closed with
interrupted Vicryl sutures followed by subcuticular Monocryl stitch and
Dermabond dressing."
I have submitted a question to the AHA Coding Clinic for HCPCS for 'official' guidance for this question.
It is a shame there is still no code specifically for the axilla.
There are so many possibilities. But there needs to be some consistent advice on this.