Wiki I&D of cyst if there no cyst was found

[goldiniryna@gmail.com]

Dear colleagues, I have an Ambulatory surgery case I would like to hear your professional opinion on. I have been strugling on it for a few days:

"" Skin incision on the hand was made and taken through skin and subcutaneous tissues. Incision and exploration continued down deep into the muscle layer. There was no cyst identified. The cyst was most likely drained by injection of local anesthesia at multiple levels. Thorough exploration was performed and still no cyst material was identified.

The wound was closed in layers with 4-0 Monocryl used to close the subcutaneous tissues together with the deep dermis. The skin was closed with interrupted 5-0 nylon. Xeroform
followed by sterile dressings were applied. ""

So, as far as I see, the 10061 (complex because they went down to the muscle) and a complex repair code ( I have to query the doc for the size) should be used.

Please let me know how would you code this procedure.
Thank you.

 

[FTessaBartels]

NO closure

You should not code the closure separately, as closure is included with surgical procedures (EXCEPT for lesion removals which require layered or complex closure).

Because the incision/exploration went deep into muscle, I would look in the musculoskeletal section of CPT for an appropriate code. I checked CPT and none of the incision, drainage or excision codes seems to fit the scenario you describe. So, you may be stuck with Unlisted Procedure CPT 26989 ... I would base my fee on 10061.

Hope that helps.

F Tessa Bartels, CPC, CEMC