Dermatology Coding Alert

Published on Sat Jan 01, 2005 PDF

Question: For reporting lipoma removal, which codes are correct: the codes for benign lesions, or the codes for excision of soft tissue mass (in this case, the mass is on the left shoulder)?


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Answer: You can report either the codes for benign lesion excisions (11400-11471) or the codes for musculoskeletal soft tissue excision (in this case, for example, 23075, Excision, soft tissue tumor, shoulder area; subcutaneous) for removal of lipoma (fatty tumor).

Tip: Before reporting, you should look to the dermatologist's documentation for specifics on the depth of the excision to support your correct code choice.

If the dermatologist's incision does not go deeper than the fascia, you are correct to choose an appropriate code from CPT's "Integumentary System" section (codes 11400-11471).

For example, if the dermatolotigst's documentation specifies "Full-thickness excision of 2.5-cm lesion (with margins) from left shoulder with simple closure," the appropriate code choice is 11403 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter 2.1 to 3.0 cm).

In this case, both the terms "full-thickness" (that is, "through the dermis") and "simple closure" should tip you off that the required incision was not very deep.

If the incision goes deeper than the fascia, the lipoma removal is not just superficial and the musculoskeletal codes are more appropriate. The dermatologist's documentation must be explicit to support the use of these codes and should specifically note the depth of the incision (such as, "past the fascia").

In the above question, if dermatologist's documentation notes a subcutaneous tumor with incision depth to at least the fascia, you may report 23075.

For even deeper incisions (subfascial or intra-muscular), you may choose 23076 (... deep, subfascial, or intramuscular).

In these cases, the size of the lipoma or the excision does not matter, as it does when reporting the integumentary codes. And you may not report the musculoskeletal codes because a lipoma reaches a certain size (for instance, more than 5 cm). Only the depth of incision, not the size of the tumor, matters.