Wiki excision


Best answers
I would code this as a soft tissue neck mass excision and use 215xx depending on the size of the mass dictated. You are thinking in the right direction about the statement "soft tissue closed in layers".
Reminds me of a childhood joke..... what do you use to shoot a white elephant? Ans: A White Elephant Gun. Ok, now what do you use to shoot a Purple Elephant? A Purple Elephant Gun...ummm no, you paint it white and shoot it with a White Elephant Gun.

Sometimes those templates want us to paint everything the same color and code it with the White Elephant brush. Unfortunately, this could result in a frown from the auditors and not to mention a visit by the game warden.

Kidding aside, you might suggest that the templates being used for your practice have a bit more leniency built into them for situations when you have a Purple Elephant and no white paint.
Sorry, couldn't help myself there but I hope I have helped you.
Inadequate documentation

There is inadequate documentation here to code anything.

Physician must specify is this is an excision of a skin lesion or excision of a tumor/cyst/mass from the soft tissue. The physician must specify the size of the lesion (measure BEFORE excision) ... if a skin lesion, size should include the margins. The physician should also specify the size of the WOUND which is being repaired. The physician needs to document the specifics of the closure (subq closed with X; epidermis closed with Y)

If this is a skin lesion you will code the appropriate excision code (based on anatomy and size), PLUS the appropriately documented layered or complex closure (simply closure is included). Finally for a skin lesion you will have to wait for pathology to know whether you have a benign or malignant lesion.

If this is a soft tissue mass, then closure is included. But you still need the size of the mass in order to code it.

Hope that helps.

F Tessa Bartels, CPC, CEMC