Wiki back mass

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Missing size for this one, what would you do?
dx- back mass
procedure - excision of back mass /

Operative read as - The patient had an elliptical incision directly over the mass on lower back near the midline.Electrocautery was used to dissect through the subcutaneous tissue to excise the mass with grossly negative margins. It apperared consistent with an epidermal inclusion cyst. The wound was irrgated with normal saline. Subcutaneous tissue was closed with interrupted 3-0 Vicryl suture and 4-0 nylon horizontal mattress and simple sutures used to close skin. The edges of skin came together easily without tension. Sterile dressing was applied. Before starting the procedure 10 cc of 1 % lidocaine with epinephrine were used for local anesthesia.
no size was dictated, so what code would you pick ?thanks,
 
you need to query the doctor and ask him what size of excision in cm was required.
you cannot rely on the path because tissue shrinks.
if you opt not to query the doctor then you have to choose the smallest excision given in the cpt book.

why throw away money if you dont have to? Query the doctor. it will be worth your time.

hope this helps
 
ok, but would you code it in range of 1140x- or 21930-21933?, i says its more 1140x , but doc office says more musculoskeletal21930-21933
 
The 11400 series of codes is for lesions that are confined within the skin only.

Since the physician dictated that he had to go thru subcutaneous tissue in order to remove the mass, it is no longer a choice of the 11400 integumentary codes, you now have to choose from the musculoskeletal section.

Your codes would be either 21930 or 21931 depending on the result of your query.

Caprice--cpc
 
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