Wiki Help with correct coding for lip cyst excision

missyah20

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Good Afternoon,

I am hoping someone can point me in the right direction for this excision of a lip cyst. I think the part that is tripping me up is that the went thru the sub-q tissue. Any help would be appreciated. Below is the operative report:

The patient was kept NPO for 8 hours pre-op. Pre-operative verification was done. Timeout was performed. Site marking was done. the patient was taken to the operating room. he was sedated by anesthetist. The patient was monitored closure by XXX. Face and lip were painted with betadine. Sterile drapes were applied. The right lower lip cyst, again, measures 1.4cm in diameter. There was no ulceration. No inflammation. No bleeding. elliptical incision was made. incision was deepened through subcutaneous tissue. The cyst wall was identified. the cyst was resected down to the orbicularis oris muscle. Complete resection of the cyst was performed with electrocautery. Hemostatis was completed with electrocautery. The subcutaneous tissue and muscle layer were approximated with interuppted stitches using 5-0 Caprosyn. The mucosa was approximated with interrupted stitches using 5-0 Caprosyn. Incision was about 2.5 cm long. There were no complications. Estimated blood loss, 1 cc of blood. Pressure was applied for 3 minutes for hemostasis. The patient tolerated the procedure well.
 
To me, it seems as if this was 40530. The note states resection, and I would certainly guess the measurement would qualify for the average person's lip measurement. (coding states more than one-fourth)
 
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