Wiki Excision coding advice

[hsmith67]

Having a debate on correct coding of the below. Any help is greatly appreciated.

Procedure: excision with intermediate layered closure
Preop diagnosis: mid back and low back lesion
Postop diagnosis: same
Location: mid back, low back Size of lesion: 1x1, 2x2cm mm Size of defect: 3, 1cm mm
Closure length: 3cm mm
Anesthesia: lidocaine 1% with epi 1:200,000 x 3 cc

Patient and procedure verifications were performed. The site was verified with the patient. Discussed potential benefits and risks including but not limited to scar formation, bleeding, infection, and the patient desired surgical treatment. Informed consent was obtained. After adequate anesthesia was obtained, the operative site was prepped and draped in usual sterile fashion. The lesion was excised with mm margins down to subcutaneous fat using a #15 blade scalpel in a fusiform fashion. The specimen was sent for pathologic examination after being marked for orientation with suture . The wound was undermined using blunt and sharp dissection. Adequate hemostasis was achieved. Closure was accomplished with 4-0 subcutaneous sutures and 4-0 epidermal sutures in a simple interrupted fashion. The site was cleaned, Bacitracin ointment was applied, and the wound was covered with a standard dressing. The patient was given detailed wound care instructions. The patient is to return for wound check/suture removal in 7-10 days. The patient tolerated the procedure well without any complications and left the office in good condition.

Hunter Smith, CPC

 

[rthomas@impcna.com]

Having a debate on correct coding of the below. Any help is greatly appreciated.

Procedure: excision with intermediate layered closure
Preop diagnosis: mid back and low back lesion
Postop diagnosis: same
Location: mid back, low back Size of lesion: 1x1, 2x2cm mm Size of defect: 3, 1cm mm
Closure length: 3cm mm
Anesthesia: lidocaine 1% with epi 1:200,000 x 3 cc

Patient and procedure verifications were performed. The site was verified with the patient. Discussed potential benefits and risks including but not limited to scar formation, bleeding, infection, and the patient desired surgical treatment. Informed consent was obtained. After adequate anesthesia was obtained, the operative site was prepped and draped in usual sterile fashion. The lesion was excised with mm margins down to subcutaneous fat using a #15 blade scalpel in a fusiform fashion. The specimen was sent for pathologic examination after being marked for orientation with suture . The wound was undermined using blunt and sharp dissection. Adequate hemostasis was achieved. Closure was accomplished with 4-0 subcutaneous sutures and 4-0 epidermal sutures in a simple interrupted fashion. The site was cleaned, Bacitracin ointment was applied, and the wound was covered with a standard dressing. The patient was given detailed wound care instructions. The patient is to return for wound check/suture removal in 7-10 days. The patient tolerated the procedure well without any complications and left the office in good condition.

Hunter Smith,

Have you gotten the path report back?

 

[Orthocoderpgu]

Once again I think the reason for the "debate" is that the documentation is not specific. The documentation does not state what tissue was dissected before reaching the nodule and what layer or layers of tissue the nodule was in. If the tumor was excised from the subcutaneous tissue, then code 21930 would be considered. However, the documentation states that the nodule was excised "down to" the subcutaneous layer, not necessarily within the subcutaneous layer. Since the subcutaneous tissue was closed with a suture, it's probable that at least part of the mass was inside the subcutaneous layer, but that is an educated guess. Per documentation there was a mid-back lesion and a low back lesion. I only see one mass excision documented, not two.

 

[hsmith67]

Once again I think the reason for the "debate" is that the documentation is not specific. The documentation does not state what tissue was dissected before reaching the nodule and what layer or layers of tissue the nodule was in. If the tumor was excised from the subcutaneous tissue, then code 21930 would be considered. However, the documentation states that the nodule was excised "down to" the subcutaneous layer, not necessarily within the subcutaneous layer. Since the subcutaneous tissue was closed with a suture, it's probable that at least part of the mass was inside the subcutaneous layer, but that is an educated guess. Per documentation there was a mid-back lesion and a low back lesion. I only see one mass excision documented, not two.

Orthocoderpgu, Thanks! That is exactly what I was concerned about as well. Ambiguity in depth as well as 2 procedures stated as done but only documented one. Thanks again.