Wiki Cpt help!

[MBA2]

Hi...

I need CPT code advise on the following;

Excision, Giant hairy nevus of the lumbosacral area measuring 4 x 5 cm

An elliptical incision was made about the previously marked skin areas and carried through the subcutaneous tissue. The lower portion of the incision traversed the nevus and the superior portion of the incision was on noninvolved skin. The incision was than carried through the subcutaneous tissue and down to the fascia of the lumbosacral muscles. This was then widely excised using electrocautery. Approximately 15% fo the nevus on the lower portion of the incision could not be excised without creating undue tension.

According to the op note only 85% of the nevus was excised.

Surgeon has indicated that this was a stage excision due to the size and complexity.

Any help will be greatly appreciated.

Thanks,
LA

 

[cmartin]

I'd still go with 11404 or 11406, depending on whether the 85% (&margins) removed was over 4cms or not. The purpose is excision for removal, it's just apparently going to be done in 2 stages.