General Surgery Coding Alert

Question: How should I code the following case?

Midline incision made 7.5 cm proximal to the xiphoid process. Fatty mass removed measuring 3 x 3 x 4.5 cm. Second fatty mass removed measuring 6.5 x 6 x 6.5 cm.  

Tennessee Subscriber

Answer: You should report the service as 49204 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5.1-10.0 cm diameter).

Four pieces of information from the op note should help you choose this code:

• The procedure is within the abdomen
• The description of access indicates that this is an open procedure
• The fatty masses, or lipomas, that the surgeon removes are a type of tumor
• There are two tumors, one measuring greater than 5.1 but less than 10 cm in diameter.

Notice plural: The code describes excision or destruction of multiple tumors, so you should report just one unit for this procedure. That also means you can’t report 49204 for the large tumor plus 49203 (…largest tumor 5 cm diameter or less) for the smaller tumor.