Wiki Elbow mass dx and cpt

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Tessimo

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The Pre and Postop Diagnosis is left elbow mass. From the OP Note: Incision was made with 15 blade centered over the subcutaneous mass which was just distal to the olecranon over the proximal ulna. Bovie cauterie was used for hemostasis. Blunt dissection was performed around the mass and it was excised. Approximately 2 cm in diameter. Not cystic. From the Path Report: Left elbow mass measuring 2.5 x 1.5 x 1.0 cm; Mass, left elbow, excision - cyst with fibrosis and chondroid metaplasia. This could represent a bursa or possibly synovial cyst.

I have the left elbow mass = R22.32; the chondroid metaplasia = M24.10; CPT 11403 for the excision; I am struggling with how to code the cyst from the subcutaneous left arm. I would appreciate your input.
 
adunlap23 said:
What about D21.9-benign neoplasm of connective and other soft tissue, unspecified?
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Thanks for the reply. I looked at that code, but it is for neoplasm and pathologist calls it a cyst. What do you think about L72.9 - index for cyst / skin - tabular = follicular cyst of the skin and subcutaneous tissue, unspecified. That might be as close as I can get.
 
You probably know we can't code anything after statements like "this could represent..." from the pathology because it's guessing. However, the fact that the pathologist didn't say "cyst of skin" or "follicular cyst" or "epidermal cyst" leads me to NOT using a code from the L72 group. It may have been a cyst within the joint and not originating in the skin, even though at that anatomical spot, a cyst arising out from the joint may be directly under the skin. Or a bursa. I don't kow off hand what other dx you could use but I wouldn't one from the L72/skin group.
 
I agree; he did not say that. The guideline for "and" should be interpreted as "and" or "or" when it appears in a title which subcutaneous is part of the code description. I was able to contact an auditor. She used L72.9 and suggested adding L90.5 to capture the fibrosis to complete the diagnosis. This has been interesting. Thank you!
 
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