Wiki Coding for removal of lipoma, no depth given

[Mklaubauf]

Hi,
My physician removed 5 different lesions. He does give size prior to removal:
Here is the wording:

"The areas were prepped with Betadine and draped in a sterile fashion. A skin wheal was raised overlying the lesion with 1% lidocaine with epinephrine, a total of 10 cc was utilized between all 5 lesions. A skin incision was made down to the encapsulated lesion which was then enucleated. They were well encapsulated and were all completely excised. A toothed forceps was used for countertraction, a Metzenbaum scissors for sharp dissection and a curved hemostat for blunt dissection. The wounds were closed with 4-0 Vicryl in a subcuticular fashion and Steri-Strips were applied with benzoin as needed. Clean occlusive dressing were applied. "

Path came back as soft tissue, lipoma.
My QUESTION: For the CPT Codes, Since he did not tell me how deep he took these lesions,how do I know if I should stay in the integumentary section or because path states soft tissue, should I code out of the Muscular Skeleton Section.

Any thoughts and anything written to this effect?
Thank you,
Marci

 

[jharo1733]

Since the physician did not note the depth in the op report, you must choose codes from the integumentary system.

 

[Mklaubauf]

Thank you for your response.
Marci

 

[FTessaBartels]

Go back to the physician

I would first query the physician. They sometimes forget to include details that are required for accurate coding.
Explain the issue and THEN code after any appropriate amendment to the documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC