Excision of Mass - Please help with the following

debraj

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Please help with the following:

After general anesthesia the patient was prepped and draped in the usual sterile fashion. We excised, by making a longitudinal incision along the thumb, what appeared to be a gouty tophus. There were two separate incisions performed with careful preservation of neurovascular structures without difficulty. The wound was copiously irrigated. The wounds were closed with 3-0 nylon. The wounds were dressed and the patient was taken to the recovery room in stable condition.

Doc wants to bill for 2 excisions of thumb and one of the index finger using CPT 26160 for all.

Is this code appropriate per the documentation?

Any help would be appreciated.
 

mbort

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Is there something missing within that documentation? If not, even though there were two incisions, I only see that he did one thing which was removing the gouti tophus, and I'm not so sure that 26160 is the appropriate code for that. Was there definitive pathology that supports a ganglion or like?
 

debraj

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no path report is available. I am in agreement that the documentation supports only the one excision, but what code would I use?
 
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