Excision epidermal inclusion vaginal cyst

such78

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Pre op diagnosis: Vaginal lesions
In pathology report " Epidermal inclusion cyst"


OPERATIVE FINDING: There was a vaginal lesion noted to be arising at the right upper vulvar area approximately 2 cm in size and another one was arising from the left upper vulvar area at approximately 1 cm in size.

Should it be coded as 57135 - removal vaginal cyst Or benign genital skin lesion excision as 11423?



Thank you for advice.
 

csperoni

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The basic rule is that any time there is a more specific code, that is what you should be coding.
57135 would seem the best choice here if this was a vaginal cyst.
I would query the provider if not clear elsewhere about it being a vaginal lesion vs a vulvar lesion.
 

such78

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The basic rule is that any time there is a more specific code, that is what you should be coding.
57135 would seem the best choice here if this was a vaginal cyst.
I would query the provider if not clear elsewhere about it being a vaginal lesion vs a vulvar lesion.

Thank you Christine.

I am going to make an query. If it returns with vulvar lesion (Epidermal inclusion cyst), and the code will be 11423.
 

csperoni

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If it does wind up being vulvar, I would also question the 11423.
11423 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm
From the limited information provided, it seems there were 2 lesions, both without exact dimensions ("approximately 2cm" and "approximately 1cm") and no mention of margins. If both were removed, I would code as below unless the pathology report provided larger than 2.0 or 1.0 respectively:
11422 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm
11421 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm

I would also confirm benign vs malignant on pathology.

Don't forget that intermediate or complex closure may be reported separately.

The lesions are coded individually. The closure (in the same body area) are added together, and only 1 code.

I would also educate my provider about documenting the size of the lesions excised INCLUDING any margins, since that is how it is coded. I have heard that lesion specimens will often shrink after removal before being examined by pathology. Explain to the physician that you want to be able to give them credit for the work they are doing, and are making suggestions regarding the documentation.
 
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