Wiki Epidermal inclusion cyst

[NPSDEB]

Hi All-

I am trying to code for removal of epidermal inclusion cyst. The tricky part is the physician only did a 8 mm X 2mm incision in which he circumferentially dissected the cyst and removed it. I understand his point of view in that it was more work to dissect the cyst & remove it from such a small opening but from a coding point of view I feel I can only bill for a 11440. He wants to bill for a 11442 for the size of the cyst before he dissected it. He is a portion of the operative report-

I first took a very small elliptical incision approximately 8 mm in length and 2 mm in width along the central portion of this nodule around the area of what was visualized at the small punctum. I did attempt to express a small amount of material from this nodule once the patient was anesthetized, but I was unable to do so. I then continued this elliptical incision down through the deep dermis and did encounter a small cyst sac. This was circumferentially dissected and removed in its entirety.


Any input is greatly appreciated.

Thank you-
Deb

 

[thomas7331]

Per CPT instructions, the code selection for excision of a lesion is based on the greatest diameter of the lesion, plus excised margins, not on the length of the incision - if the size of the lesion is documented, that's what you should use. It is not uncommon for the length of the incision to be less than or greater than the size of the lesion itself, but it would not be correct to code for a smaller or larger lesion just because of a difference in the length of the incision that was made to approach the lesion.