Wiki Hydrocystoma can I bill??

[Coder123!]

Good Morning, I'm new to Dermatology and I was wondering can you bill for a Hydrocystoma? It was 1 lesion by the eye extracted using an 11 blade and this is all that was performed. I know it's not an abscess so we can't charge the 67700 but I just don't know if I can charge anything? Thoughts? THANK You!

 

[thomas7331]

I think we'd need to see the documentation of the procedure in order to be able to guide you on this. 'Extracted using an 11 blade' doesn't give enough information to be able to properly assign a code.

 

[Coder123!]

Thank you Thomas for you reply. The doctor had this under the plan, no procedure note. She did state it was a 5 mm translucent papule however nothing was sent to pathology so if a dermatologist doesn't send anything to pathology we can't bill for the procedure correct? Thank you again for your time

 

[thomas7331]

Thank you Thomas for you reply. The doctor had this under the plan, no procedure note. She did state it was a 5 mm translucent papule however nothing was sent to pathology so if a dermatologist doesn't send anything to pathology we can't bill for the procedure correct? Thank you again for your time

Sending a specimen to pathology is not a requirement to bill for a procedure, but you do need a sufficiently detailed operative report to be able to code and charge it accurately. Just 'removing' a papule is not a reportable procedure without documentation of the technique and instrumentation used, the length of the incisions and margins, depth of the tissue where it was located, type of closure or repair, etc.