Wiki CPT help please - trigger thumb

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irishhawk

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Happy Monday, can I ask your help?

Soft tissue mass, right thumb:
Non-specific fibrosis, myxoid degeneration, and chronic inflammatory change. The histologic findings are consistent with tenosynovitis (trigger thumb).

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Is this a straight-up 88307 for soft tissue mass? I am hesitant, because some other tendon / synovium tissues are 88305s or 88304s.

thank you !
 
Soft tissue mass

Hi Irishhawk ~ Happy Tuesday,
There is limited information provided to assist you with solid answers.
Level V (88307) requires the specimen to be a certain size and margins need to be checked.
Are you able to provide the reason why the specimen was provided for the pathology review with the macro information including the size of the soft tissue mass. LxWxD please.
Also what does the microscopic state? Tenosynovitis is inflammation of the lining of the sheath that surrounds a tendon, so I am hoping that with just a little more information I would be able provide better advice on which CPT to apply.
Thanks for all your help,
Dana Chock, CPC, CCA, CANPC, CHONC, CPMA, CPB
Anesthesia, Pathology & Laboratory Coder
 
Hi Dana, happy Wednesday!

ok: the clinical info is just "trigger thumb"
The microscopic is the part I originally posted ;
the gross is "soft tissue mass right thumb / the specimen consists of a 1.3x 0.9 x 0.6cm irregular fragment of yellow-white soft tissue.."

I know, it's not much to go on, but I hope this helps you help me!

thanks,
Megan
 
Hi Megan ~ Happy Sunday,
The dimensions provided do not qualify for a Level V - soft tissue mass......
Based on what you provided I would apply a Level IV for soft tissue, other than tumor, mass, lipoma, debridement. Without mention of tendon or tendon sheath ~ I wouldn't apply the Level III.
Thanks
Dana
 
Thank you very much for your expertise Dana --- and on a Sunday, no less! It's okay with me if you take today off. :)

Megan
 
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