Wiki Excision 11400 or 25075

[mfournier]

Hello Everyone:

I was wondering if someone can take a peek at this op note. The path states lipomas but don't his documentation supports 25075.

Preoperative diagnosis: Multiple lipomas of the left forearm
Postoperative diagnosis: Same
Procedure: Excision of 2.5, 2.1, 1.5, 1.6, 1.1, 1.3 centimeter lipomas of the left forearm

Findings: Multiple lipomas as above

Procedure: The procedure was performed in the minor surgical treatment area. The patient was transferred to the operating table in the supine position. The area was anesthetized with local anesthetic. Incision was made directly over the lipomas and the underlying lipomas were excised completely with a combination of blunt, sharp dissection techniques with a 15 blade and Metzenbaum scissors. They were passed off a specimen. The wounds were then closed with a 4-0 Monocryl intradermal layer. The wound was dressed with Steri-Strips. The patient tolerated the procedure well. All sponge needle and instrument counts correct at the end of the case.

Thanks in advanced
Miriam

 

[Orthocoderpgu]

I suggest working with your provider on increasing the specificity of the documentation. Code 11400 is for the removal of basically epidural lesions. Code 25075 is for the removal of deeper subcutaneous lesions. In this case lipomas. There's no doubt that this is what the provider did, however the documentation does not support the code since the provider never mentioned the tissue depth. If you look at the difference in RVU's, it's worth the providers time.

 

[mfournier]

Great thank you for your input.