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Wiki Need help with Mass Removal CPT

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kkindle1807

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Can someone please look at this Op note and advise what CPT code I should use. The lab report came back with Dx of Infected Ulcer of finger. The physician gave me a CPT code of 26116 which is not correct as this is not Malignant. Thank you in Advance.
 

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26116 is not correct based off size. 26113 is what I would code based off size, and location. with dx of R2231,D481 and final diagnosis of ulcer.
 
LIVE2CODE said:
26116 is not correct based off size. 26113 is what I would code based off size, and location. with dx of R2231,D481 and final diagnosis of ulcer.
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Lab tests came back as L98.498 -ulcer & L08.89 -infection, this seems more of an incisional biopsy but we're not sure what CPT to use as it went to phalanx level.
 
Did your doctor go back an remove the remainder of the mass? if not this would in my opinion be more excisional since he removed all of the mass at that time. He removed soft tissue note bone.
 
LIVE2CODE said:
Did your doctor go back an remove the remainder of the mass? if not this would in my opinion be more excisional since he removed all of the mass at that time. He removed soft tissue note bone.
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No, there was just this one surgery and the lab results came back stating it was an infected ulcer, nothing malignant, no neoplasm
 
I would code 26210 Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger;. since the op report describes the mass being at the bone level: "the mass was mobilized at its base at the distal phalanx level and then excised... The base of the mass was debrided with the rongeur" (a rongeur is an instrument used for removing bone)." Since we don't have anything in the ICD-10 index under mass, bone or mass, finger, and it is not a tumor, I would go to "disorder, bone" and find M89.8X4 Other specified disorders of bone, hand for a mass of the finger.
 
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