Excision of Back Mass??? Some please help Clarify???

amny1212@yahoo.com

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Hello Everyone,
I am a new Coder working In General Surgery and i need help with this Op report ,please can anyone help??

OPERATION: EXCISON OF BACK MASS,2CM SIZE; EXCISION OF UPPER BACK MASS;5MM SIZE AND EXCISION OF LEFT CHEST MASS; 1CM SIZE

PROCEDURE:
THE PATIENT WAS PLACED ON THE OPERATING ROOM TABLE IN A SUPINE POSITION AND RECEIVED SATISFACTORY INTRAVENOUS SEDATION AND PREOPERATIVE INTRAVENOUS ANTIBIOTICS.A TIME OUT WAS DONE.

WE PROCEEDED WITH THE EXCISON OF THE LEFT ANTERIOR CHEST MASS FIRST.THE LEFT ANTERIOR CHEST AREA WAS PREPPED AND DRAPED IN THE USUAL STERILE FASHION.LOCAL ANESTHESIA WAS ADMINISTERED FOR TRANSVERSE INCISION DIRECTLY OVER THE MASS WHICH APPEARED TO BE A CYST.AN INCISION WAS MADE TO ALSO INCLUDE REMOVAL OF AN APPARENT SKIN PUNCTUM FOR THIS CYST AND EXCISION WAS DONE WITH SCAPEL AND ALSO SHARP DISSECTION WITH METZENBAUM SCISSORS.HEMOSTASIS WAS SATISFACTORY.THE LEFT CHEST MASS WAS ABOUT 1CM SIZE.THE SPECIMEN WAS SENT TO THE PATHOLOGY.CLOSURE WAS SONE USING 4-0 MONOCRYL SUBCUTICULAR SKINCLOSURE.STERI-STRIP,GAZE AND OPSITE DRESSING APPLIED.

THE PATIENT WAS PLACED IN RIGHT LATERAL DECUBITUS POSITION WITH APPROPRIATE SHOULDER ROLL,BACK MASSES WERE LOCATED SOMEWHAT MIDLINE AND IN THE UPPER BACK REGION.THE UPPER BACK REGION WAS PREPPED AND DRAPED IN THE USUAL STERILE FASHION.THERE WERE TWO MASSES ON THE BACK.THE SMALLER UPPER BACK MASS WAS ABOUT 5MM IN SIZE AND LOCAL ANESTHESIA WAS ADMINISTERED.TRANSVERSE INCISION WAS MADE AND THIS MASS INCLUDING APPARENT SKIN PUNCTUM WAS REMOVED AND SENT TO PATHOLOGY.CLOSURE WAS DONE USING 4-0 MONOCRYL SUBCUTICULAR SKIN CLOSURE.

THE LARGER BACK MASS WAS ABOUT 2CM IN SIZE.LOCAL ANESTHESIA WAS ADMINISTERED AND VERTICAL ELLIPTICAL INCISION WAS MADE TO ALSO INCLUDE APPARENT SKIN PUNCTUM.THIS MASS WAS EXCISED AND SENT TO PATHOLOGY.CLOSURE WAS DONE USING MULTIPLE 4-0 MONOCRYL IN SUBCUTANEOUS CLOSURE AND ALSO IN SUBCUTICULAR SKIN CLOSURE.STERI STRIPS,GAUZE ANS OPSITE DRESSING APPLIED.

My co-workers in the office (more experienced than I am) suggest I use 11406.
But for I cannot seem to agree.Can someone please assist me on this Op??

thank you in advance,
:confused:
 

cmartin

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They're wrong. You don't add the sizes of the lesions together. You code each by the size of actual lesion plus minimum margins required. If the actual lesions were 1.0, 0.5 and 2.0cms, most likely they would be 11402, 11401, & 11403. The largest lesion it sounds as though the subq was closed separately from the skin? If so, you could also bill 12031 or 12032 for that (it breaks @ 2.5 cms). Adjust codes accordingly if you have more specific info re the sizes.
Incidently, IF all 3 lesions had had intermediate closures, you WOULD add them together for THATpart, but NOT for the excisions.
 

cmartin

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CPT book under heading "Excision - Benign Lesions" = "Report separately each benign lesion excised." forgot to cite authority!:)
 
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