Wiki EXCISION OF GANGLION CYST

[CCANTER]

If a patient has a mass at the dorsal aspect of the wrist and the provider thought it was a ganglion cyst but it ended up not being one can we still use the CPT code for the excision of the ganglion cyst CPT code 25111

here is the op note

The right upper extremity was prepped and draped in normal fashion. An incision was made over the dorsal aspect of the wrist in a classic location for a dorsal wrist ganglion. Retractors were inserted, and almost immediately, a muscle belly was encountered. There were some extensor tendons wrapped up in this muscle belly, and these were all teased away from the muscle belly and reflected. There was no ganglion cyst that I could see. The origin proximally and distally of this muscle, which obviously is not usually in this location, could not be determined. We copiously washed out the wound, made sure the tendons were all freely flowing, and closed the subcutaneous with 2-0 Monocryl, and 3-0 Prolene closed the skin.

 

[Orthocoderpgu]

If a patient has a mass at the dorsal aspect of the wrist and the provider thought it was a ganglion cyst but it ended up not being one can we still use the CPT code for the excision of the ganglion cyst CPT code 25111

here is the op note

The right upper extremity was prepped and draped in normal fashion. An incision was made over the dorsal aspect of the wrist in a classic location for a dorsal wrist ganglion. Retractors were inserted, and almost immediately, a muscle belly was encountered. There were some extensor tendons wrapped up in this muscle belly, and these were all teased away from the muscle belly and reflected. There was no ganglion cyst that I could see. The origin proximally and distally of this muscle, which obviously is not usually in this location, could not be determined. We copiously washed out the wound, made sure the tendons were all freely flowing, and closed the subcutaneous with 2-0 Monocryl, and 3-0 Prolene closed the skin.

If your provider did not remove a ganglion cyst you cannot bill for the removal of a ganglion cyst. As coders our job is to make sure that the documentation supports the codes submitted.

 

[CCANTER]

ok thank you. I didnt think that i could. the procedure is listed as then an exploration and dissection through a mass of the right dorsal wrist. I do not feel like any mass was excised. so i can't use a cpt code for just an excision of a mass. Do you have any ideas for what i could use for this procedure?

 

[amyjph]

From what you snipped from the op report above it sounds like work on the extensor tendons but not a tenotomy or tenolysis. There's really no wrist code for just exploration unless it's a scope which this wasn't. Maybe you could consider 25110 or 25111 with modifier 52 (?). Since the intent was to do 25111 but once they got in there they discontinued it. There's no good way to try and report this. If I was coding it I would probably do this and it may require op report submission and explanation.

Or, you could query the provider to see if the provider feels this was tenolysis (25295) since it was stated, "There were some extensor tendons wrapped up in this muscle belly, and these were all teased away from the muscle belly and reflected." But, this seems kind of weird to me too.