I have a general surgeon who is coding 216.5, V49.89. which returned patholgy dx of lipoma . here is the op report, your input is greatly appreciated.
The pts abdomen was draped in the usal sterile fashion. Local anesthesia was administered and a transverse incision was made with a scapel. dissection was carried down through the subcutaneous tissues to the lipoma. The lipoma was well encapsulated in some areas and more vaguely encapsuted in others. It was multiobulated and redunculted. It was carefully dissected from from the surrounding subcutaneous tissues. It was passed off for pathology. It was measured 8cm in maximum length. The incision was irrigated and then local anesthesia was administered. It was closed using interrupted 3-0 Vicryl in the subscutanous layer, 3-0 in the dermal layer and running 5-0 Vicryl, steri strips and Mastisol. The incision was measured at 5cm.
The surgeon is coding the procedure as 11406 with closure of 12032, I feel that since physician is stating that he went to the subq, would 22903 be more appropriate with dx of 214.8. I code for an ASC and our codes should match, but not sure about this one.
HELP
Paula
The pts abdomen was draped in the usal sterile fashion. Local anesthesia was administered and a transverse incision was made with a scapel. dissection was carried down through the subcutaneous tissues to the lipoma. The lipoma was well encapsulated in some areas and more vaguely encapsuted in others. It was multiobulated and redunculted. It was carefully dissected from from the surrounding subcutaneous tissues. It was passed off for pathology. It was measured 8cm in maximum length. The incision was irrigated and then local anesthesia was administered. It was closed using interrupted 3-0 Vicryl in the subscutanous layer, 3-0 in the dermal layer and running 5-0 Vicryl, steri strips and Mastisol. The incision was measured at 5cm.
The surgeon is coding the procedure as 11406 with closure of 12032, I feel that since physician is stating that he went to the subq, would 22903 be more appropriate with dx of 214.8. I code for an ASC and our codes should match, but not sure about this one.
HELP
Paula