Wiki Coding soft tissue mass

[jodielonkoski]

Hello! I am an outpatient anesthesia coder; we work with a lot of ortho centers, and I see a lot of 'soft tissue mass' diagnosis. Since we only code the anesthesia we don't often get the path report, but I do get the OP report. When the provider documents a 'mass' alone I use an R22 code, when they specify the mass is in the soft tissue, I am unsure if that R code would still be best, or if I should use M79.89 - Other specified soft tissue disorders.
Occasionally in the OP report the provider will specify the type of mass, but often it is unsure until the path comes back, which we do not get.
Any advice on which code you would pick would be helpful!

 

[jodielonkoski]

Any takers?

 

[danachock]

Hello jodielonkoski,
I'll walk through my rationale if that may assist you. I was an anesthesia coder for many years (also working specifically denials for a satellite) for several years.
But I saw your post and lack of (takers) comments and wanted to try to help you this evening.

Okay, lets walk through a fictious coding scenario together.
Soft Tissue Neck Mass

Next, we review the index; and the "Mass" with subcategory of "neck" brings us to R22.1
We continue onto the tabular to validate code selection. Local swelling, mass and lump, neck

Again, I hear your concerns about the "soft tissues disorders" so I reviewed the index (again) to be sure I did not miss something here.
I am scrolling through all the subcategories provided here and the only thing that catches my eye is "specified organ NEC" that states to "see Disease, by site."
I head to the "Disease" area of the tabular and there is no mention of "soft tissue". I cannot make this up.
I know my example was horribly fictious; but wanted to drive the review of both the index and tabular for diagnosis assignment.

That is my rationale this evening; there was no mention of soft tissue disorder only a mass; that I provided a fictional example of this evening and my personal rationale for coding assignment without the pathology report to fall on here.

Unfortunately, you are unable to capture the pathology report to drive the more specificity diagnosis assignment, but if this is what you have to code from for providing anesthesia; that would be my route.
If anyone else has something to offer, I'd love to hear your response.
Thank you so much for listening and have a wonderful evening.
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT

 

[amyjph]

Hello! I am an outpatient anesthesia coder; we work with a lot of ortho centers, and I see a lot of 'soft tissue mass' diagnosis. Since we only code the anesthesia we don't often get the path report, but I do get the OP report. When the provider documents a 'mass' alone I use an R22 code, when they specify the mass is in the soft tissue, I am unsure if that R code would still be best, or if I should use M79.89 - Other specified soft tissue disorders.
Occasionally in the OP report the provider will specify the type of mass, but often it is unsure until the path comes back, which we do not get.
Any advice on which code you would pick would be helpful!

Do you have an example? Unfortunately, this is common in ortho op notes. There's really nothing else to use if they don't specify and you can't get the path report. It's the R22. A lot of times they end up being ganglions, bursal cysts, etc. Sometimes it's just a lipoma in the D17 area.
If it was the hands I would start wondering about rheumatoid nodules and/or sometimes Dupuytren's but they generally already know that and specify those in the op note.
You're going to be stuck with the R's otherwise. I see how you could possibly go with the M79.89 too though. I think it will just depend on exactly what each note states.
If they say the word "mass" and you follow the ICD-10 index, you end up at R.

 

[jodielonkoski]

Hello jodielonkoski,
I'll walk through my rationale if that may assist you. I was an anesthesia coder for many years (also working specifically denials for a satellite) for several years.
But I saw your post and lack of (takers) comments and wanted to try to help you this evening.

Okay, lets walk through a fictious coding scenario together.
Soft Tissue Neck Mass

Next, we review the index; and the "Mass" with subcategory of "neck" brings us to R22.1
We continue onto the tabular to validate code selection. Local swelling, mass and lump, neck

Again, I hear your concerns about the "soft tissues disorders" so I reviewed the index (again) to be sure I did not miss something here.
I am scrolling through all the subcategories provided here and the only thing that catches my eye is "specified organ NEC" that states to "see Disease, by site."
I head to the "Disease" area of the tabular and there is no mention of "soft tissue". I cannot make this up.
I know my example was horribly fictious; but wanted to drive the review of both the index and tabular for diagnosis assignment.

That is my rationale this evening; there was no mention of soft tissue disorder only a mass; that I provided a fictional example of this evening and my personal rationale for coding assignment without the pathology report to fall on here.

Unfortunately, you are unable to capture the pathology report to drive the more specificity diagnosis assignment, but if this is what you have to code from for providing anesthesia; that would be my route.
If anyone else has something to offer, I'd love to hear your response.
Thank you so much for listening and have a wonderful evening.
Dana Chock, CPC, CANPC, CHONC, CPMA, CPB, RHIT

Thank you, I really appreciate this! I am a newer coder so still getting my sea legs, so to speak. I appreciate the break down! That makes sense and I will keep using the R codes.

 

[jodielonkoski]

Do you have an example? Unfortunately, this is common in ortho op notes. There's really nothing else to use if they don't specify and you can't get the path report. It's the R22. A lot of times they end up being ganglions, bursal cysts, etc. Sometimes it's just a lipoma in the D17 area.
If it was the hands I would start wondering about rheumatoid nodules and/or sometimes Dupuytren's but they generally already know that and specify those in the op note.
You're going to be stuck with the R's otherwise. I see how you could possibly go with the M79.89 too though. I think it will just depend on exactly what each note states.
If they say the word "mass" and you follow the ICD-10 index, you end up at R.

I do not currently have an example, but I agree it is frustrating when I am sure if I had the path, I could be more accurate. Thank you, I will use the R codes as that does seem to make the most sense with the index.

 

[amyjph]

I do not currently have an example, but I agree it is frustrating when I am sure if I had the path, I could be more accurate. Thank you, I will use the R codes as that does seem to make the most sense with the index.

Assuming you aren't in a shared record system like with Epic and the hospital or something? When in ortho practice in my past, we could get path reports which was helpful because the op notes were lacking as you have seen many times. And, sometimes the path doesn't come back right away.

 

[jodielonkoski]

Assuming you aren't in a shared record system like with Epic and the hospital or something? When in ortho practice in my past, we could get path reports which was helpful because the op notes were lacking as you have seen many times. And, sometimes the path doesn't come back right away.

We are contracted with a few facilities, for the 2 ortho facilities we use one we just get sent the OP report and anesthesia record but nothing else, the other we have an online portal where we get the anesthesia record and occasionally will have the OP or path, so unfortunately, we're pretty limited with info we get. But yeah it seems, especially for a 'mass', we really need the path to code any more specifically than the R code.