Wiki excision of mass , tumor , lesion ?

[kdkamleshkd@gmail.com]

my provider documented this much only

Procedure: RIGHT WRIST EXCISION OF TUMOR
Pre-op diagnosis: Localized swelling, mass and lump, right upper limb
Post-procedure dx: Localized swelling, mass and lump, right upper limb.

how it will be coded from this much documentation ? and why ?
i considered it as tumor and coded 25075- D49.89as dx, is it correct ?

 

[sls314]

my provider documented this much only

Procedure: RIGHT WRIST EXCISION OF TUMOR
Pre-op diagnosis: Localized swelling, mass and lump, right upper limb
Post-procedure dx: Localized swelling, mass and lump, right upper limb.

how it will be coded from this much documentation ? and why ?
i considered it as tumor and coded 25075- D49.89as dx, is it correct ?

Your diagnosis should be R22.31 (Localized swelling, mass and lump, right upper limb)

D49.89 is neoplasm of unspecified behavior of other specified sites. That diagnosis would not be appropriate for the documentation listed above. (If you had pathology results stating that the histological nature of that mass cannot be determined, then you could use an unspecified behavior neoplasm code. If there's no pathology and you're just coding from the documentation above, then R22.31 would be appropriate.)

Your documentation isn't specific enough to state whether the procedure was done under localized or general anesthesia, and it also doesn't state the size of the mass removed.

However, CPT 25075 is for an excision from the subcutaneous soft tissue. Your documentation states the mass was localized, not subcutaneous.

Here's some additional information that you can find in your CPT book for the code range 25075-27078, including other code ranges that you can review: