Dermatology Coding Alert

Published on Sat Dec 17, 2016 PDF

Question: How would I code for the removal of a mobile lipoma from the right flank over the ribs? The encounter note states the physician performed the procedure “using good local block excised through a 12 cm incision in an encapsulated 7x6.5 cm lipoma.”

Illinois Subscriber

Answer: It depends on the depth of the lipoma the physician removed. If the lipoma was subcutaneous, you should report 21931 (Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater).

If notes indicate that the lipoma was subfascial or intramuscular, however, 21933 (Excision, tumor, soft tissue of back or flank, subfascial [e.g., intramuscular]; 5 cm or greater) is probably your best bet.

To be safe, check with the provider who performed the service if you have any doubt as to the depth of the lipoma.