Orthopedic Coding Alert

Question: Our surgeon excised rheumatoid nodules on the right and left elbows. The nodule on the right elbow was accompanied by sinus tracts which were also excised. The operative note read as follows:

“The large voluminous nodule on the left arm was first approached through a posterolateral incision approximately 12 cm in length. On this side, there were no draining type sinuses. The rheumatoid nodule was identified along the lateral border and then lifted up off the olecranon and triceps fascia. This was brought over, taking it off the medial side of the elbow, taking care to not violate the cubital tunnel retinaculum and protecting the ulnar nerve. This was then dissected off the skin, leaving a very thick flap and not spitting out the skin at all. The wound was copiously irrigated, the tourniquet was let down, the skin was closed with interrupted 3-0 nylon everting sutures, and a sterile, soft supportive dressing was applied. On the right side, there were two draining sinus type tracts almost straight posteriorly overlying the rheumatoid nodule. The incision on this side was an elliptical incision incorporating these two sinus tracts slightly eccentric to the lateral side. The mass was then shelled out, keeping again thick flaps and debriding it up off the olecranon triceps fascia. Once again, care was taken to protect the nerve, not violating the cubital tunnel retinacular area. The excised nodules on the left and right sides were sent for pathological examination.”

Please help us to report these procedures.

Wisconsin Subscriber

Answer: You may read in the pathology examination report and confirm the size of the nodule on the left elbow. Depending upon the size of the nodule, you report code 25075 (Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm) or 25071 (Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greater).

On the right elbow, your surgeon is making an elliptical incision to excise the sinus tracts along with the nodule. In this case, you report code 24071 (Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater) – 24076 (Excision, tumor, soft tissue of upper arm or elbow area, subfascial [e.g., intramuscular]; less than 5 cm) for the nodule excision. Once again, you may confirm the size of the nodule in the pathology report.