One of my providers removed a dilated pore of Winer, and I am struggling to decide on the appropriate codes to use. (I work in primary care, so derm is not my strong point!)
First, can anyone confirm the ICD-10 I should be using? I don't know if it should be a follicular disorder or some sort of acne.
Diagnosis aside, I'm more concerned in coming up with the appropriate CPT code(s) for the removal. The procedure note is below. I am partly thrown because here she refers to it as a "cyst," but throughout the rest of the note it is referred to as a lesion, and specified as a pore of Winer. (It's entirely possible she just selected the incorrect EHR template and "cyst" was entered automatically") The closure is also throwing me. Should this be a 10040 and simple closure code? Or a benign lesion excision and removal?
"Cyst Removal:
The patient complains of changing lesion.
Indication: inflamed lesion
Procedure #1: incision of skin and removal of cyst
Size (in cm): 0.4
Comment: dilated pore of Winer
Instrument used: #11 blade
Anesthesia: 1% lidocaine w/epinephrine
Superficial Suture: 5-0 Nylon
# of superficial sutures: 1
Cleaned and prepped with: betadine
Wound dressing: bacitracin
Instructions: RTC in 5 days"
I'm leaning toward the lesion excision, but like I said, derm is not my strong point. Any guidance toward the right answer here would be very much appreciated! Thank you!
First, can anyone confirm the ICD-10 I should be using? I don't know if it should be a follicular disorder or some sort of acne.
Diagnosis aside, I'm more concerned in coming up with the appropriate CPT code(s) for the removal. The procedure note is below. I am partly thrown because here she refers to it as a "cyst," but throughout the rest of the note it is referred to as a lesion, and specified as a pore of Winer. (It's entirely possible she just selected the incorrect EHR template and "cyst" was entered automatically") The closure is also throwing me. Should this be a 10040 and simple closure code? Or a benign lesion excision and removal?
"Cyst Removal:
The patient complains of changing lesion.
Indication: inflamed lesion
Procedure #1: incision of skin and removal of cyst
Size (in cm): 0.4
Comment: dilated pore of Winer
Instrument used: #11 blade
Anesthesia: 1% lidocaine w/epinephrine
Superficial Suture: 5-0 Nylon
# of superficial sutures: 1
Cleaned and prepped with: betadine
Wound dressing: bacitracin
Instructions: RTC in 5 days"
I'm leaning toward the lesion excision, but like I said, derm is not my strong point. Any guidance toward the right answer here would be very much appreciated! Thank you!