Sebaceous Cyst Excision

tfrick2

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How would you code this?

"Preop Diagnosis: Left hip sebaceous cyst.
Postop Diagnosis: Same.
Name of procedure: Excision of 2 cm left hip sebaceous cyst.
Operative Findings: The cyst wall was removed in its entirety along with the inspissated sebaceum which was partially exposed through an opening in the skin prior to surgery.
Procedure: ...Left hip was prepped and draped in the standard sterile fashion. The visible and obvious lesion was identified and a planned ellipse marked around the lesion to include the opening through which the inspissated sebaceum was extending. The area was anesthetized...An incision was made and carried down through the skin into subcutaneous tissue. Taking care to keep the cyst wall within the incised tissue, dissection was performed circumferentially around the cyst wall using sharp dissection with scissors. The cyst was delivered intact and passed off the operative field as specimen for pathologic review. Meticulous hemostasis was achieved using electrocautery. The deep dermis was reapproximated with interrupted 3-0 Vicryl suture. The skin edges were reapproximated with 4-0 subcuticular Monocryl. The wound is washed and dried. Steri-strips and a dressing were applied."

**My main question is, would you code this as an excision of a sebaceous cyst 10040, or a skin lesion 11402?**


Thank you,
Tracy
 
Last edited:

brightpea

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you would use 11402. don't forget about the closure - i could be wrong, but this looks like an intermediate closure to me. you could also be able to bill 12031. hth!
 
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