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Help Coding Exc. Inf Cyst back

Hopp

Guru
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Hi! Just wondering if anyone would be able to help coding following:
Exc 3 cm inf.cyst of the back that was excised to the muscle fascia and elevated off the
muscle fascia using Bovie. Exam.of superior flap revealed approx.1cm residual cyst wall ext.proximally and this was sharply dissected out. Wound irrigated. An incision was made in lower flap and 1/4 inc drain placed. Subcu tissues were approx.using 2-0 and skin closed using interrupted 3-0. etc,etc.
Path: Granulaoma left back, Tissue- Cyst wall
Here is what I was thinking, but wanted confirmation: 11403 and 12032
Dx: 706.2 TIA for any help!
Deb, CPC
 

nsteinhauser

Expert
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That's what I would use. Were you wondering about 21931? Did the path say 'epidermal inclusion cyst' or 'sebaceous' or did they just say 'cyst'?
 

Hopp

Guru
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Coding Exc Cyst back

Thank you so much for your help with this: Path: Granuloma left back Tissue: Cyst wall
Also, When or would you use the 2000 codes for an excison of cyst?
Please let me know as I am still very confused about the 2000 codes
TIA Deb,CPC
 

Lujanwj

Guru
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Doesn't sound like you would use the 20000 series code for this instead use 11400, depending on size. Take a look at the guidelines for Benign Lesions which says "Cystic Lesions". Most cysts like this will originate in the skin not the subcu or musle (soft tissue/20000). Code from where the lesion originates. You use the 20000 series for tumors that originate in Subcu or Muscle (soft tissue).

You might be able to bill the repair as well. 11401 and larger allows for intermediate and complex repairs per NCCI.
 

Lujanwj

Guru
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I highly suggest not using 21931. This simple fact is Dr excised a Cyst not a TUMOR. The description of 21931 specifically states TUMOR and a Cyst is not a Tumor. A Cyst is a Cystic Lesion as defined in CPT Guidelines for Benign Lesions (p.62). CPT Guidelines and CPT Code Description should be enough for you to make the correct decision. Good luck.
 
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Cyst excision

I think we need to code the CPT based on the extent the procedure was done. So in case if cyst was excised from the level of muscle/fascia, it would be suggestable to use 2xxxx codes.

Because i came across a scenario, a large cyst was excised by incising in to till deep fascia and it was excised . Pathology also mentioned it as skin and softissue sebaceous cyst.
Any one please clarify , if iam wrong?


Arun G
CPC
 
Last edited:

cynthiabrown

True Blue
Local Chapter Officer
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I have always coded cyst from 11000 series with repair if layered add a code for infection as well as 706.2
 
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