Wiki General Sugery coding help please

[BeckyL1958]

I need help coding this please. I am not experienced at general surgery at all and any help will be appreciated. p.s. especially with modifiers! Thank you!

Pre and Post Op DX
"Multiple pigmented skin lesions"
Operation
"Excision of multiple pigmented skin lesions"

The patient was given IV Sedation as neded per the anesthetist. The patient was place prone. The back was prepped and draped in sterile fashion. There were 4 lesions of concern on the back - 2 on the right and 2 on the left. Each of these were excised with small ellipses transversely. The 2 on the left were each about 2.2 cm acros, and about half the height. On the right, one was also 2.2 cm, and the other about 1.5 cm.

All of these were closed with 4-0 Monocryl subcutaneous and subcuticalur sutures. Steri-strips completed their closure.

We then repostioned the patient to the left lateral decubitus position and cauterized some nevi on her neck - again under local 1% lidocaine with epinephrine being utilized.

There were no complications.

 

[sferguson]

skin lesion

Is this something they send off for biopsy?
If so you need to wait for the report to come back to code it either malignant or benign. Also you look in your CPT for the body region and sz of the lesion, as specified by the Dr not the report because they shrink in pathology. Make sure you also code the closure and if there are multiple closures in the same area you need to add them up and use one code.
Example
repair 2.5 cheek
repair 1.4 nose
total same area 3.9
use 12052

If you need anymore help please don't hesitate to ask.

 

[FTessaBartels]

Code each excision separately

You code each lesion excision separately ... by size.

Simple closure in included in the lesion removal. Layered/intermediate or complex closure would be coded separately, in addition to the excision. You would group the same type/body area together and code once for the combined length of the closure.

Hope that helps.

F Tessa Bartels, CPC, CEMC