Wiki Pathology report

[codedog]

Pathology Report says received in formalin is an elliptical piece of skin with underlying soft tissue with measures 2.5 x 0.07 with a depth of 1.8cm .This is an excisional biopsy of anterior chst wall mass. Doctor only stated he went subcutaneous in operative report. Pathlogy also concluded it was in epidermal inclusio cyst-706.2
Now DO i code 11403 or 21555-, always have trouble with this , can someone explain how they would do this ? thanks -and Happy Holdays -trent

 

[bench]

11403 is a procedure of the integumentary system involving full thickness of the skin (epidermis and dermis) including subcutaneous. 21555 is in the musculoskeletal system. Look in the op-report if the excision involves the muscle even tho the tumor is only in the subcutaneous level you can use 21555, but if the excision is only limited to full thickness and subcutaneous with out involvement of the muscle, use 11403 + the type of closure. If the closure is an advance tissue transfer or flap, you will only report the closure since the excision portion is inclusive. I hope this helps.

Lay description of 21555 from asc expert.com.:
The physician removes a tumor from the soft tissue of the neck or anterior thorax (chest) that is located in the subcutaneous tissue in 21555 and in the deep soft tissue, below the fascial plane or within the muscle.