Wiki Lipoma remove 11406/12031 vs 21552

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cnramsey

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I get conflicting information when I read the posts regarding this scenario. Some coder say you automatically code lipomas from the Musculoskeletal system. Others say if the documentation does not state how deep than you code from the Integumentary section. So please give me as much feed back as you like regarding this Op note. Thanks again!

Preop Dx Right Chest wall lipoma
PostOp Dx Right 6.5 x 4 cm right chest wall lipoma that is deep(Can I use this Deep do code from the musculoskeletal section?)
Procedure Excision of right chest wall lipoma deep greater than 4 cm
Staff Surgeon Dr A
Anesthesia Local anesthesia by myself
Indications: The patient is a year old with right chest wall lipoma that is increasing in tenderness.

Procedure in Detail: The area was prepped and draped with betadine prep swabs. Local anesthesia was infused in the skin and subcutaneous tissues. An incision was made. The lipoma was identified and dissected out circumferentially. This was measured at 6.5 x 4 cm. I obtained hemostasis with a electrocautery. Once this was accomplised, I closed the wound in two layers with a 4-0 vicryl and skin was closed with 4-0 vicryl. Steri-Strips were applied. Sterile dressing was applied. The patient tolerated procedure well.
 
Texascoder64 said:
Here is a good resource in determining CPT codes for excising Lipomas

https://www.billing-coding.com/detail_article.cfm?articleID=6132
Click to expand...
Thank you for the link it helped me a lot. I have asked my provider to append the actual location ie stating subcutaneous depth for the lipoma removal. After reading the link it states the subcutaneous, fascia and muscle are in the lowest level. So would it be appropriate to use his description of lipoma deep to code from the musculoskeletal section?

Thank you,
Nichole
 
I have always asked my physicians to be sure to indicate the layer/depth in their documentation in order to keep it very clear. They can do this by saying an incision was made down to the non-muscular fascia, or something to that effect. It lets anyone reading it have a good understanding of where the lesion was.
 
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