Wiki CPT 26160 pr 26111 Mass Finger

[cwilson3333]

Title of procedure: Incision and drainage of mass, flexor surface, distal portion of right index finger

Portion of op note: Patient had mass at flexor surface distal to distal crease. L-shaped incision made with apex at flexor crease on radial side of finger, flexor crease upside. Dissection carried down. There was a mass. Looked like sebaceous material in it. Clearly a cystic wall. Removed in its entirety...…………………………….

Confused on which code to use
26160 or 26116
Have differing opinions in office?

Thanks
CW

 

[thomas7331]

I don't think your documentation is adequate for code selection, just based on what you've given here. 26160 specifies a lesion of tendon sheath or joint capsule whereas 26116 is subfascial or intramuscular, but neither of these would be supported since the type of tissue where this mass is located or the depth of the dissection is not documented. Perhaps your pathology report would give you more information, but I would query the provider. My thought, though, is that if this in fact a sebaceous cyst as the note would suggest, it is most likely involves the skin and subcutaneous tissues, in which case neither of those codes would be appropriate and a benign lesion excision, e.g. 11420, would be more correct.