Look to Soft-Tissue Tumor Codes for a Lipoma Excision
Question: I have a surgical report that lists the procedure as an excision of a 4 cm subcutaneous lipoma from the patient’s neck. How should I report this procedure? West Virginia Subscriber Answer: Assign 21552 (Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater) to report the excision of the lipoma from the patient’s neck. Condition definition: A lipoma is considered a benign (noncancerous) soft-tissue tumor made up of mature fat (adipose) cells. The growths commonly develop in the subcutaneous tissue, which is located between the skin and the fascia or muscle. Lipomas can also grow deeper in muscle (intramuscular lipoma) or below the fascia (subfascial lipoma). Lipomas are usually painless, develop slowly over years, can move freely under the skin, and are soft and rubbery to the touch. Since lipomas are considered soft-tissue tumors, you’ll use a soft-tissue excision code to report the procedure. Your code selection for a lipoma excision is based on multiple factors, including: In your case, the growth occurred on the neck, at the subcutaneous level, and it measured 4 cm in size. These factors lead you to 21552. You’ll also use D17.0 (Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck) as the diagnosis code for the procedure. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
