Wiki epidermal inclusion cyst

[NPSDEB]

Hi All-

I am trying to code for removal of epidermal inclusion cyst. The tricky part is the physician only did a 8 mm X 2mm incision in which he circumferentially dissected the cyst and removed it. I understand his point of view in that it was more work to dissect the cyst & remove it from such a small opening but from a coding point of view I feel I can only bill for a 11440. He wants to bill for a 11442 for the size of the cyst before he dissected it. He is a portion of the operative report-

I first took a very small elliptical incision approximately 8 mm in length and 2 mm in width along the central portion of this nodule around the area of what was visualized at the small punctum. I did attempt to express a small amount of material from this nodule once the patient was anesthetized, but I was unable to do so. I then continued this elliptical incision down through the deep dermis and did encounter a small cyst sac. This was circumferentially dissected and removed in its entirety.


Any input is greatly appreciated.

Deb

 

[ltrue]

Why 11440?

I would actually code 11441 due to 8mm + 2mm = 10mm = 1.0 cm. If it were 0.1 cm or 1 mm more, I would agree with your doctor.

 

[thomas7331]

Both of these would be incorrect. Per CPT guidelines "code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision" - you cannot use the length of the incision to infer the size of the lesion or choose the coding for the excision. If the size of the lesion is not documented in the record, you should query the physician for that information.