Wiki CPT CODE for Removal of epidermoid cyst using Hemostat

[cmanion]

The lesion site was marked and confirmed by patient. ‎‎After consent was obtained the patient was placed in a lateral position and the area was prepped with Betadine. Hemostat was used to grab the cystic structure and was removed and An antibiotic dressing was applied.‎

Does anyone know how this would be coded? It is an epidermoid skin on the upper back, procedure done in office

 

[thomas7331]

It's not clear to me what technique the provider actually used to remove this cyst - I don't know how a cyst can be removed simply by 'grabbing' it. Was there an incision made first in order to access the cyst? If this is all that was dictated, it appears to me that the documentation it incomplete. I would query the provider if you are able to. If all that the provider did was pluck something from the surface of the skin, then it probably doesn't warrant a separate code for a surgical procedure.

 

[chantal777]

The lesion site was marked and confirmed by patient. ‎‎After consent was obtained the patient was placed in a lateral position and the area was prepped with Betadine. Hemostat was used to grab the cystic structure and was removed and An antibiotic dressing was applied.‎

Does anyone know how this would be coded? It is an epidermoid skin on the upper back, procedure done in office

Good morning,
What was the size of the lesion? the physician used an hemostat to grab the cyst, in order for him to use the hemostat to grab the cyst I believe he made an incision first using a scapel. I would assign code 11400-->excision of benign lesion including margins, except skin tag, trunk, arms, or legs; excised diameter 0.5cm or less. (when you don't have the exact measurement of the lesion use the smallest measurement in the code selection.


[2000/08] Excision of a lesion CPT Assistant August 2000
The Removal of a Lesion

To properly code an excision of a lesion, the physician must document the size and location of the lesion. The size of a lesion is measured by its clinical diameter for a circular or elliptical lesion. The diameter is the length of a straight line segment that passes through the center of a figure, especially of a circle or sphere, and terminates at the periphery. If the lesion is asymmetrical or irregular, the maximum width is used to measure the lesion. The physician should make an accurate measurement of the lesion at the time of the excision, and the size of the lesion should be documented in the operative report. A pathology report is less likely to contain an accurate measurement due to the shrinkage or fragmentation of the specimen. When coding the removal of a lesion, do not report the size of the surgical defect created or the affected area.

Example: A physician excises a 0.3 cm malignant lesion on the back. In this case, the appropriate CPT code would be 11600.

Example: A physician excises an asymmetric benign lesion on the neck measuring 1.0 cm by 2.0 cm. The appropriate CPT code, based on the maximum width of 2.0 cm, would be 11442.

Example: A physician excises a malignant lesion of the nose measuring 1.0 cm in diameter, and the total skin margins equal an excision of 2.1 cm. The appropriate CPT code, based on the 1.0 cm in diameter, would be 11641. It would be incorrect to use code 11643, based on the 2.1 cm diameter, which includes the excision and skin margins.
[2018/09] Lesion excision clarifications
Simple repair is used when the wound is superficial (eg, involving primarily epidermis or dermis, or subcutaneous tissue without significant involvement of deeper structures). Wound closure involves closing one layer, including local anesthesia, and chemical or electrocauterization of wounds not closed.

Hope that helps
Chantal

 

[cmanion]

Good morning,
What was the size of the lesion? the physician used an hemostat to grab the cyst, in order for him to use the hemostat to grab the cyst I believe he made an incision first using a scapel. I would assign code 11400-->excision of benign lesion including margins, except skin tag, trunk, arms, or legs; excised diameter 0.5cm or less. (when you don't have the exact measurement of the lesion use the smallest measurement in the code selection.


[2000/08] Excision of a lesion CPT Assistant August 2000
The Removal of a Lesion

To properly code an excision of a lesion, the physician must document the size and location of the lesion. The size of a lesion is measured by its clinical diameter for a circular or elliptical lesion. The diameter is the length of a straight line segment that passes through the center of a figure, especially of a circle or sphere, and terminates at the periphery. If the lesion is asymmetrical or irregular, the maximum width is used to measure the lesion. The physician should make an accurate measurement of the lesion at the time of the excision, and the size of the lesion should be documented in the operative report. A pathology report is less likely to contain an accurate measurement due to the shrinkage or fragmentation of the specimen. When coding the removal of a lesion, do not report the size of the surgical defect created or the affected area.

Example: A physician excises a 0.3 cm malignant lesion on the back. In this case, the appropriate CPT code would be 11600.

Example: A physician excises an asymmetric benign lesion on the neck measuring 1.0 cm by 2.0 cm. The appropriate CPT code, based on the maximum width of 2.0 cm, would be 11442.

Example: A physician excises a malignant lesion of the nose measuring 1.0 cm in diameter, and the total skin margins equal an excision of 2.1 cm. The appropriate CPT code, based on the 1.0 cm in diameter, would be 11641. It would be incorrect to use code 11643, based on the 2.1 cm diameter, which includes the excision and skin margins.
[2018/09] Lesion excision clarifications
Simple repair is used when the wound is superficial (eg, involving primarily epidermis or dermis, or subcutaneous tissue without significant involvement of deeper structures). Wound closure involves closing one layer, including local anesthesia, and chemical or electrocauterization of wounds not closed.

Hope that helps
Chantal

Great information, Thank you

 

[cmanion]

This is the response I got from the physician: I used a number of tools to remove the lesion- no incision made- I used hemostats and scoop to remove the lesion.

 

[thomas7331]

This is the response I got from the physician: I used a number of tools to remove the lesion- no incision made- I used hemostats and scoop to remove the lesion.

If no incision was made, this is not an excisional removal. I would use 17110 for this, or an unlisted code. Per CPT guidance on excisions, "for electrosurgical and other methods see 17000 et seq."