Wiki Excision Epidermal Cyst

[drhoads]

Physician removed an epidermal cyst midback area 4.5 cm.
Description of procedure: Following satisfactory placement of the pt prone on the operating room table, sterile prep and drape of the left midback overlying the large epidermal cyst was accomplished and monitored anesthesia care was administered. After satisfactory anesthesia, a 15-blade was used to trace an ellipse, encompassing the cyst in the midline. The ellipse measured 55 x 28 mm wide and 55 mm in a longitudinal transverse manner. Bleeding points were controlled with electrocautery then electrocautery was used to dissect the subcutaneous tissue off down to the back fascia and excise the ellipse which was 55 x 24 x 28 mm. Following this, the incision was approximated with 2-0 monocryl and the skin was closed with 4-0 monocryl in a running subcuticular manner and then sereral 2-0 prolene sutures were placed as well as retention sutures. Patient was flipped onto his back and trasported on the operating room stretcher to the recovery room.

Not sure if i should use 21931 or 11406 and 12032. PLease help!!

 

[code4u70]

I would code 11406 and 12032, since the documentation states "down to the back fascia", so you are still in the skin and subcutaneous tissue, not the muscle.

 

[HAFFORD]

I would code 21931 because the cyst is in the subcutaneous tissue.

 

[drhoads]

I can see it both ways....still undecided which way to code????

 

[Texascoder64]

If the cyst is in the subcutaneous tissue I would be leaning toward the soft tissue codes 21931 (remember repair is inclusive)
You could compare your fee allowables for each
114xx with repair code (multi surg rule applies)
vs.
21931
see which one pays more. Either set of codes would be appropriate.