biopsy Code

Trendale

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Jacksonville, FL
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Hi,
I am not sure which BX code to use for the following coding scenario. Can someone help me with the following scenario?

Procedure-Biopsy of mass RT groin
The physician did an incisional biopsy. Dissection was carried down through the skin and subQ tissues. Scarpa fascia was divided.. A portion of the large mass was excised using sharp dissection. The sub Q tissues were approximated using interrupted sutures. The skin was closed using subcuticular suture.

The codes I was contemplating on using was 49180, but in the CDR description, it says no incision was necessay. In the OP report, he did a skin incision. The other code was 11100, there is no mention of an incision. (says surgically removes, may be done with a scapel)

Thanks!
 
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4,456
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Milwaukee WI
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27040-41

I agree with RainyDaze ... 27040 or 27041 depending on depth.
Based on what you provided, the surgeon did go into the fascia, so I'd probably use 27041.

F Tessa Bartels, CPC, CPC-E/M
 
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