I&D suture granuloma

jhorton86

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I am struggling with how to code this...

Postop diagnosis: Foreign body cyst/ granuloma reaction post total knee arthroplasty.
Operation performed was I&D, removal of foreign body suture/cyst/granuloma.

Procedure summary: Left leg prepped and draped in usual sterile fashion. Time out performed. Draining sinus was located. It was the most distal portion just medial to the tibial tuberosity. Utilizing previous incision a 2cm elliptical incision was made and completely removed the small 2mm sinus. Upon removing it, the sinus tracked into a bulbous cystic region, possible early granuloma formation, what was completely elliptically removed and appeared to have some old monocryl suture within it. I further debrided the underlying tissue and irrigated copious amount of normal saline and bacitracin solution.


Dr. wants to code 27301 but I am not so sure.
Thank you!
 
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Durham, NC
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Hello jhorton86,

I don't think CPT 27301 is the correct code as it is for I&D of deep abscess, bursa or hematoma and this is appears to be a cyst excision. Since within the documentation it does not seem the provider drained the cyst but that it was already draining on it's own so an I&D code would not be appropriate. I am thinking that a CPT code from 11400-11402 would be fitting along with possibly debridement (11042? with modifier). I also recommend querying the provider on the depth of debridement.
 
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