Help Coding this Op Report!

[ksamples]

I coded this Op Report as 11442 and 12051 and the MD stated that this was more complex and deep than a regular excision. He stated that these codes wouldn't work. Any suggestions?

Diagnosis: Left temple/forehead lesion

Procedure: Excision of lesion with intermediate/deep closure.

The patient was brought to the Operation Room, placed under MAC anesthesia. Injection was performed with 1% lidocaine post 1:100,000 epinephrine. Incision was made in a crease just above the left eyebrow and this was carried down using blunt dissection to the mass. It appeared to be a lipoma and this was shelled out using blunt and sharp dissection. It appeared to be just under the skin. The mass was removed in its entirety. Adequate hemostasis was obtained and a small peice of surgicel was placed in the inferior aspect of the wound for hemostasis. The wound was closed in layers with a 4-0 chromic for deep layer and the skin was closed with a 6-0 fasting absorbing gut.

 

[FTessaBartels]

Better documentation needed

Well he can "say" that it was more complex, but he did not document that.

To use 21011 thru 21014 he will need to stipulate how deeply he dissected ("to the mass" doesn't tell me how deep the mass was - subcutaneous? subfascial? Intramuscular?) -and- the size of the mass (Cm measured at widest diameter). And don't forget that closure is INCLUDED with codes in the musculoskletal section of CPT.

You should also have confirmation from pathology that this was a lipoma.

Hope that helps.

F Tessa Bartels, CPC, CEMC