Orthopedic Coding Alert

Question: Our surgeon did an open excision of a lipomatosis nodule of the sinus tarsi on both sides. How can we report this?

Maryland Subscriber

Answer: For the lipoma, you may report code 28041 (Excision, tumor, soft tissue of foot or toe, subfascial (e.g., intramuscular); 1.5 cm or greater) or 28045 (Excision, tumor, soft tissue of foot or toe, subfascial (e.g., intramuscular); less than 1.5 cm) depending upon the whether the lipoma is more than or less than 1.5 cm in size. The sinus tarsus is neither a joint nor a ligament. It is a space.