Wiki Excision of multiple sebaceous cyst

[forddani19]

Can someone please help!-
A patient came in the 12 sebaceous cyst on his scrotum ranging in size from 5mm to 2cm. They were all removed. In the cpt book it says to code each lesion seperately. Has anyone else had someone like this, do you really code all 12 seperately for the same area.

 

[sheardmd]

Yes, you have to code them all separately. Use the 59 modifier, ins will prob ask for records. We've had to do this many times for lipomas and sebaceous cysts.

 

[forddani19]

Thank you for your help! I just have one more question. He does not list the size of them, he just says 12 sebaceous cysts ranging in size 5mm in diameter up to approximately 2cm in diameter. I received the path report and the individual sizes are not listed on there either. Do I just code them all to the smallest size?

 

[koatsj]

I would go back to the surgeon and ask him to give you the sizes. He should have documented that in the operative report to begin with. Of course, this is not a perfect world

 

[sheardmd]

I would have him do an addendum if he can remember the sizes since ins may ask for records.

 

[tcooper@nmhs.net]

The surgeon needs to do an addendum to the operative note but you also might look at the office visit note and see if he documented sizes in the body of the office note. Sometimes our surgeons list the sizes on the office note...Yes we have had patients that have had over 20 cyst removed at one surgical setting....