Wiki Help Code Excision

[drhoads]

Procedure: Excisional bx of bilateral lower back masses. DX: Lipomas

Area was incised with a 15 blade and carried down through the subcutaneous fat with electrocautery. The mass was again palpated. Dissection was carried out onto the mass and it was then dissected from the surrounding tissues. The base of the mass was adherent to the posterior part of the pelvis. It was amputated with electrocautery. The right side was attended to first and after finished it was paced with a gauze. The left side was attended to in like fashion. Both sides were irrigated and fried. Hemostasis was achieved electrocautery. The deep tissues were reapproximated with 2-0 chromic interrupted fashion. The dermis was reapproximated with 3-0 Vicryl in interrupted fahion. The skin was reapproximated with 4-0 Monocryl in a running subcuticular fashion. The wounds were washed and dried and benzoin and steri-strips were applied.

I am looking at cpt 21931 LT and 21931 59-RT

Size of left =4.5 x 3 x 2cm
Size of right= 4.5 x 4 x 2cm

I always seem to question myself when it comes to these types of procedure. Code from the Integ. or Muscle???

 

[bevlewis07]

I would think only code from the integumentary system because muscle was not documented that it was removed

 

[Kevinph84]

The physician did state deep tissues were closed. Then proceeds to document the closing of the dermis and skin. I would review the operative report with the physician for clarification. When chosing which code to utilize, it is selected based on the origin of the lesion. If the lesion is soft tissue based (deep subcutaneous tissues) and/ or and intramuscular, then you may report from the 20000 series. If the lesion origin is from the dermis (regardless of how radical the excision may be), you would stick to using the codes from the integumentary section. I would educate the physician in his documentation of lipoma origin (skin versus deep subcutaneous versus intramuscular). Best Wishes