Soft Tissue Codes

Kevinph84

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New Port Richey & Gulf to Bay
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Hello Everyone,

I was wondering if I could get some advice. For the soft tissue tumor codes, should they only be reported for soft tissue tumors only? Here is an example:

The patient comes in for surgery for a soft tissue mass of right ankle. The provider goes through the skin and subcutaneous tissue to excise the 3 cm lesion. The lesion appears to be just above the retinaculum. The skin and subcutaneous layers were closed. The lesion was sent to pathology, where pathological analysis revealed the mass to be an organizing thrombus.

If it was a soft tissue tumor, I would've used:

27632
Excision, tumor, soft tissue of leg or ankle area, subcutaneous; 3 cm or greater

Now we have an organizing thrombus. Could we still use the 27632 with diagnosis 453.6, or should I use the following CPT with the corresponding diagnosis:

27613
Biopsy, soft tissue of leg or ankle area; superficial

Thank you all for your help.
 

Bella Cullen

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Messages
499
Best answers
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Hello Everyone,

I was wondering if I could get some advice. For the soft tissue tumor codes, should they only be reported for soft tissue tumors only? Here is an example:

The patient comes in for surgery for a soft tissue mass of right ankle. The provider goes through the skin and subcutaneous tissue to excise the 3 cm lesion. The lesion appears to be just above the retinaculum. The skin and subcutaneous layers were closed. The lesion was sent to pathology, where pathological analysis revealed the mass to be an organizing thrombus.

If it was a soft tissue tumor, I would've used:

27632
Excision, tumor, soft tissue of leg or ankle area, subcutaneous; 3 cm or greater

Now we have an organizing thrombus. Could we still use the 27632 with diagnosis 453.6, or should I use the following CPT with the corresponding diagnosis:

27613
Biopsy, soft tissue of leg or ankle area; superficial

Thank you all for your help.
I would code this as 27632 with 238.1 primary dx and 453.6 secondary dx.

Because you didn't know it was a thrombus until path came back so that is why I would code the reason for the tumor excision as the first diagnosis and the findings of what it is as secondary dx.
 
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