Wiki lipoma coding

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lovetocode

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Patient had a subcutaneous mass of the scalp. Surgeon removed mass and sent to pathology to discover it was a lipoma. This is the entirety of the operative report:

Preop dx: Subcutaneous mass of scalp
Postop dx: Subcutaneous mass of scalp
Procedure: Excision of subcutaneous mass of scalp
Anesthesia: MAC and local
EBL: Min
Findings 2 cm fatty mass c/w lipoma
Specimen 2 cm round mass of scalp
Complications: none
Condition: Stable

Please advise on how to properly code. Would you use 11422 for an excision of a benign scalp lesion, or would you code it 21011 for an excision of a scalp tumor in the subcutaneous tissue?

I would suggest the 21011 because a lipoma is a benign tumor composed of adipose tissue.
 
lovetocode said:
Patient had a subcutaneous mass of the scalp. Surgeon removed mass and sent to pathology to discover it was a lipoma. This is the entirety of the operative report:

Preop dx: Subcutaneous mass of scalp
Postop dx: Subcutaneous mass of scalp
Procedure: Excision of subcutaneous mass of scalp
Anesthesia: MAC and local
EBL: Min
Findings 2 cm fatty mass c/w lipoma
Specimen 2 cm round mass of scalp
Complications: none
Condition: Stable

Please advise on how to properly code. Would you use 11422 for an excision of a benign scalp lesion, or would you code it 21011 for an excision of a scalp tumor in the subcutaneous tissue?

I would suggest the 21011 because a lipoma is a benign tumor composed of adipose tissue.
Click to expand...

Since lipomas are usually found in subcutaneous tissue, not in the skin, the musculoskeletal section of CPT is the place to look. So 11422 is not the right code and I think instead of 21011 you should use: 21012 Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater
 
However ...

However ... your documentation is sorely lacking in my opinion to code ANYTHING.

Surgeon doesn't mention incision, type of closure, etc.

I would not be comfortable assigning either code to this documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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