Wiki Orhto

[daniel]

Diagnosis: Lipoma of the wrist

procedure: excision of lipoma


Procedure code for this is?

thank you
Daniel, CPC

 

[FTessaBartels]

Look at Excision codes

Look at the Excision codes in CPT under "Forearm and Wrist." (pg 100 of 2008 CPT Professional Edition)

F Tessa Bartels, CPC, CPC-E/M

 

[daniel]

OP report.

As follows. After a successful anesthetic, the patient was positioned on the operating table, a toruniquet applied to the upper arm. The extremity was prepped in the usual manner for a surgical procedure and draped off. The superficial vessels were exsanguinated with an elastic wrap, and the toruniquet was inflated to the usual arm pressure.
A longitudinal incision was made over the presenting mass which was just volar to the superficial branch of the radial nerve. The mass was encapsulated with some fatty tissue extending from it. This was dissected out with blunt and sharp dissection, and care was taken to protect additional sensory nerve that was identified. After dissecting out the mass, it was submitted for specimen. it appeared to be a lipoma.



CPT: 25075: Excision, tumor, soft tissue of forearm and/or wrist area: subcutaneous.


This is what I get. Do you agree.

Respectfully
danie, CPC

 

[FTessaBartels]

Yes,

Daniel ... I"m not an expert at ortho codes, but Yes, I'd agree with you on 25075.

My only question would be that mention is made of the radial nerve and fatty tissue extending from the lipoma. Someone more expert in the anatomy of the forearm/wrist can tell whether this might indicate a deep excision.

Secondly, since the specimen was sent to pathology, you might want to wait for a definite diagnosis of the mass before finalizing your coding. (You may have already done that ... )

F Tessa Bartels, CPC, CPC-E/M