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Lesion Removal

lori85210

Contributor
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Lesion Removal

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This may sound silly but I read the report below and came up with 11443 but my provider states it should be 67412 because he went into the muscle. Please let me know who is right.

DX: Dermal inclusional Cyst. (per pathology report)

After the administration of anesthesia, the patient was
prepped and draped aseptically. Preoperative antibiotics were
administered. Incision was designed and executed after injecting Marcaine
with epinephrine. Incision was designed right next to the brow. Incision
was taken through the skin, subcutaneous tissue, and then through the
musculature. The mass was then encountered. Sharp and blunt dissection
was then performed to isolate the mass. We then went after the bottom of
it. It significantly indented the bone underneath. We then removed the
mass in its entirety. There was no full-thickness penetration. The wound
was copiously irrigated. It was a dermoid. The closure was then performed
with interrupted Vicryls in the muscle and dermis followed by absorbable
sutures in skin. Antibiotic ointment was applied. The patient's care was
turned over to Anesthesia. Lesion was 2.5 cm
__________________
LORI
 

mitchellde

True Blue
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Columbia, MO
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67412 states the lesion is in the orbit and the approach is subciliary, frontal (thru the lid), or transconjunctival. I have not found a better match than 11443 and I was certain that there would be! You could always append a 22 if you really feel the documentation supports it.
 
Last edited:
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Hello, I am a little late with a response, but I definitely agree with everyone that CPT 11443 is correct, but don't forget that a layered closure was performed (The closure was then performed with interrupted Vicryls in the muscle and dermis followed by absorbable sutures in skin), therefore, CPT 12051 should be billed as well.

Jennifer
CT ENT
 
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