Wiki Cyst removal coding-HELP!! - confirming adequate anesthesia

[britbrit852003]

Two coders in my office are coding the following cyst removal differently I need opnions on how others would code this.
Per the provider the cyst size was 3.0cm x 2.0cm but he only did an incision of 1.5 cm for cosmetic reasons. So the lesion and the incision were two different sizes. Any help is grealty appreciated on this issue.

Procedure Note

Exam-
Skin:
3cm x 2cm x 1cm cyst mid back at midline. no evidence of infection

Cyst Removal Note:
The patient complains of pain, tenderness, and swelling.
Size (in cm): 3.0 x 2.0
Comment: cyst removal mid central back: reviewed risks/benefits, consent signed. pt placed in prone position, cyst cleaned with betadyne x 3 and alcohol swabs x 3. area anesthesized with 2mL 1% lidocaine with epinepherine using 30 ga 1" needle. after confirming adequate anesthesia, #11 blade scapel used to make 1.5cm linear incision made center of cyst. using forcep and tissue scissors cyst excised/teased out relatively intact. cavity explored and any further tissue removed without difficulty. area closed with 3 4-0 simple interupted sutures with good wound approximation. no complications, pt tolerated well

Additional Instructions: pt to notify office of any problems/concerns assoc with cyst removal site or sutures. return suture removal 10 days

 

[BEARDOG]

Two coders in my office are coding the following cyst removal differently I need opnions on how others would code this.
Per the provider the cyst size was 3.0cm x 2.0cm but he only did an incision of 1.5 cm for cosmetic reasons. So the lesion and the incision were two different sizes. Any help is grealty appreciated on this issue.

Procedure Note

Exam-
Skin:
3cm x 2cm x 1cm cyst mid back at midline. no evidence of infection

Cyst Removal Note:
The patient complains of pain, tenderness, and swelling.
Size (in cm): 3.0 x 2.0
Comment: cyst removal mid central back: reviewed risks/benefits, consent signed. pt placed in prone position, cyst cleaned with betadyne x 3 and alcohol swabs x 3. area anesthesized with 2mL 1% lidocaine with epinepherine using 30 ga 1" needle. after confirming adequate anesthesia, #11 blade scapel used to make 1.5cm linear incision made center of cyst. using forcep and tissue scissors cyst excised/teased out relatively intact. cavity explored and any further tissue removed without difficulty. area closed with 3 4-0 simple interupted sutures with good wound approximation. no complications, pt tolerated well

Additional Instructions: pt to notify office of any problems/concerns assoc with cyst removal site or sutures. return suture removal 10 days

When a benign skin lesion is removed you would use the 11400 series of codes. You would include the excised dimensions which would make this one 11406 ("Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm "). If it is a commercial carrier (not CMS) you can also charge A4550 , however, that would depend on your contract if it is reimbursable or not. CMS does not allow for a surgical tray, however, some private carriers, a few, do.

I hope this was helpful for you.